Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Madison Co Nh during CMS and state inspections, most recent first.
A resident with advanced dementia and severe cognitive impairment sustained a bruised left eye and facial bruising after being struck by a CNA. The CNA initially claimed the injury occurred accidentally while pushing the resident to a dining table and denied hitting the resident, but an LPN and another CNA reported that the resident stated she had hit the CNA and was hit back in the eye, demonstrating a slapping motion. Nursing documentation described left orbital ecchymosis, bruising along the bridge of the nose and cheek, tenderness, minimal edema, and the resident’s complaint of soreness, confirming a significant injury resulting from the physical abuse.
Infection control practices were not followed during resident care for two residents. An RN performing catheter care used a contaminated washcloth on the catheter site and touched a bathroom door handle while wearing contaminated gloves. An LPN administering PEG tube meds entered without hand hygiene, touched multiple surfaces with the same gloves, did not wear a gown, and exited without hand hygiene; the LPN stated she had not received EBP training.
Failure to assess and monitor full side rails as a restraint: A resident with a stroke history and severely impaired mental status was observed with both side rails fully raised. Staff confirmed the rails were used at family request after a prior fall, but less restrictive alternatives were not tried, a pre-restraint eval was not documented, and the facility did not consistently assess or document the rails as a restraint or monitor their ongoing need.
A resident with chronic kidney disease was given a morphine dose ten times higher than prescribed after an LPN used a medication cup instead of a calibrated syringe, as the pharmacy did not supply one. The error was discovered during a narcotic count, and the resident experienced respiratory depression requiring Narcan administration. Staff interviews and records confirmed the error resulted from improper measurement and failure to follow protocol.
A resident's controlled medication, oxycodone, was found to be missing after only a portion of the delivered pills were documented as administered. Investigation revealed that 36 pills were unaccounted for, and the medication card was not found in the designated shred box, despite an LPN's statement that it had been disposed of. The DON confirmed the missing medication and documentation, resulting in a finding of narcotic diversion and misappropriation of resident property.
A resident was observed sitting in a public area with her breast exposed due to an ill-fitting tank top, compromising her dignity. Despite having appropriate clothing available, staff failed to ensure she was dressed properly. An LPN acknowledged the issue and attempted to cover the resident, while the DON confirmed the exposure was a dignity issue.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in their care. A resident with hemiplegia was observed with unshaven facial hair and soiled clothing, indicating non-compliance with the ADL care plan. Another resident requiring assistance with ADLs was found with food stains on her clothing, suggesting staff did not follow the care plan. Additionally, a resident's care plan lacked documentation for a physician-ordered left-hand splint, which was not included in the care plans or electronic care guide.
The facility failed to assist two residents with activities of daily living (ADLs). One resident was found with unshaven facial hair and soiled clothing, while another had food remnants on their clothing after meals. Staff interviews confirmed that the residents were dependent on staff for these tasks, but the necessary care was not provided.
A resident with cerebral palsy and hemiplegia was not provided with a left-hand splint as required, leading to a deficiency in maintaining their range of motion. The splint order was initially entered into the system but was removed and not re-entered, resulting in the resident not wearing the splint. Staff interviews confirmed the oversight, and the resident's severe cognitive impairment further complicated the situation.
A facility failed to properly clean and store a PEG tube syringe, leaving it on a bedside table without a clean barrier or storage bag, contrary to policy. An LPN admitted to the oversight, and the Infection Control Nurse confirmed the increased risk of infection to a resident who received all medications and nutrition via the PEG tube. The resident had diagnoses including Cerebral Palsy.
Failure to Protect Cognitively Impaired Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse, resulting in the resident being struck in the eye by a CNA. Facility records show that a CNA reported to an LPN that the resident had a bruised left eye and initially stated the injury may have occurred while pushing the resident to the dining table due to the resident’s short, stooped posture. The CNA also reported that the resident used a racial slur toward her and that she verbally responded but denied striking the resident. However, subsequent interviews and the facility’s investigation determined that the resident’s injury was not caused by accidental contact with the dining table. Interviews with staff revealed conflicting accounts that led to the conclusion that the resident had been hit. An LPN stated that the resident reported being hit in the eye by the CNA and that another CNA heard a commotion and later observed bruising to the resident’s left eye. When this second CNA asked what happened, the resident reported that she hit the CNA and was hit back in the eye, while making a motion consistent with a slap. The LPN confirmed that the resident gave a similar account to her, indicating that the CNA had physically struck the resident. The resident involved was admitted to the Memory Care Unit with diagnoses including Alzheimer’s disease, cognitive communication deficit, and unspecified dementia with behavioral disturbance, and had a BIMS score of 5 indicating severe cognitive impairment. A nursing progress note documented an acute follow-up assessment of left orbital ecchymosis, describing a dark red circular bruise to the left eye region, dark purple bruising along the lateral bridge of the nose extending to the superior left cheek, tenderness on palpation, minimal edema, and the resident’s complaint that the area was sore. Due to advanced Alzheimer’s disease, the resident was unable to reliably express additional symptoms, but the documented physical findings supported that the resident sustained a significant injury to the eye area as a result of being struck by the CNA.
Infection Control Practices Not Followed During Resident Care
Penalty
Summary
Provide and implement an infection prevention and control program was not ensured when staff failed to follow infection prevention practices during resident care. Facility policy required hand hygiene after contact with body fluids, after removing gloves, and use of Enhanced Barrier Precautions for residents with wounds or indwelling devices. During observation of catheter care for one resident with a recent UTI treated with antibiotics, an RN dropped a washcloth onto the bed linen, retrieved it, and used the same contaminated washcloth to cleanse the catheter site. The RN then touched the bathroom door handle while still wearing contaminated gloves. The RN stated she should have discarded the washcloth and performed hand hygiene after removing gloves before touching environmental surfaces, and the DON and IP confirmed this was expected practice. During observation of PEG tube medication administration for another resident with severe cognitive impairment, an LPN entered the room without performing hand hygiene, wore the same gloves while touching multiple surfaces including the faucet, medication cart, computer mouse, privacy curtain, and bed controls, did not don a gown, administered medications via PEG tube without changing gloves or performing hand hygiene, and exited the room after removing gloves without performing hand hygiene. The LPN stated she had not received training on Enhanced Barrier Precautions and acknowledged failing to perform hand hygiene, wear a gown, and change gloves. The IP and DON stated the nurse should have performed hand hygiene on entry, worn a gown, and changed gloves after contact with environmental surfaces.
Failure to Assess and Monitor Full Side Rails as a Restraint
Penalty
Summary
The facility failed to ensure that other alternatives were tried before full side rails were installed for Resident #42 and failed to assess and monitor the side rails as a restraint to determine whether they were medically necessary and the least restrictive intervention. The resident was observed lying in bed with both side rails in the full up position, functioning as full-length side rails. The resident had diagnoses including cerebral infarction (stroke), and the MDS showed a BIMS score of 99, indicating severely impaired mental status. During interviews, an LPN confirmed the resident had full side rails in use and stated she did not consider them a restraint and was unsure of the clinical justification. She reported the resident was total care and unable to reposition independently, and that staff did not assess or document the side rails as a restraint or monitor their continued necessity. An RN stated a pre-restraint evaluation should have been completed but could not provide documentation, and said the side rails were used at the request of the family after a prior fall. She confirmed less restrictive alternatives were not implemented before the side rails were initiated. The DON stated the side rails were in place due to family requests to prevent falls, that the facility does not assess restraints daily, and that documentation is not completed each shift; she also stated weekly notes are entered but no consistent monitoring process is in place. The physician order dated 4/15/25 ordered full 3/4 bilateral rails to prevent leaning and falling out of bed, and the restraint evaluation form was undated and did not include the resident's name.
Significant Medication Error Due to Incorrect Morphine Administration
Penalty
Summary
A significant medication error occurred when a resident was administered an incorrect dosage of morphine sulfate. The physician's order specified a dose of 0.25 ml of morphine concentrate to be given as needed, but the LPN on duty administered 2.5 ml, which was the lowest measurable line on the plastic medication cup used. The pharmacy did not provide a calibrated syringe with the medication, and the LPN was unable to locate one in the facility. Instead of seeking further guidance or delaying administration, the LPN used the medication cup, which was not suitable for measuring such a small dose. The error was discovered during the end-of-shift narcotic count, which revealed a discrepancy in the morphine supply. Following the administration of the incorrect dose, the resident experienced a significant change in condition, including decreased oxygen saturation, bradycardia, and respiratory depression. Progress notes documented that the resident became difficult to arouse and eventually unresponsive, with vital signs indicating respiratory compromise. Emergency services were contacted, and Narcan was administered, resulting in improvement of the resident's vital signs. The resident had a history of chronic kidney disease, which can affect morphine metabolism and increase the risk of adverse effects. Interviews with facility staff and the pharmacy consultant confirmed that morphine sulfate should only be administered using a calibrated oral syringe to ensure accurate dosing. The use of an inappropriate measuring device directly led to the overdose. The facility's policy and FDA guidance both require the use of a calibrated syringe for morphine administration, and the failure to follow these protocols resulted in a significant medication error and harm to the resident.
Narcotic Diversion and Misappropriation of Resident Medication
Penalty
Summary
A deficiency occurred when a resident's controlled medication, specifically oxycodone, was found to be missing from the facility's narcotic storage. The facility's policy defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident's belongings without consent. In this case, 120 oxycodone pills were delivered for a resident, but only 24 pills were documented as administered according to the Medication Administration Record. Upon investigation, it was discovered that 36 pills were unaccounted for, and the medication card was missing from the designated shred box, despite staff statements that it had been properly disposed of. The Controlled Drug Record and pharmacy receipts confirmed the delivery and subsequent removal of the medication card, but the required documentation and physical evidence of the card's destruction were absent. Interviews with the DON and LPNs involved revealed inconsistencies in the handling and documentation of the resident's narcotic medication. The DON confirmed that she was unable to locate the medication card or the corresponding narcotic sheet in the appropriate storage locations. The resident involved was cognitively intact, as indicated by a BIMS score of 15, and had an active order for oxycodone 10 mg every six hours as needed for pain. The failure to account for all administered and remaining pills, as well as the lack of proper documentation and secure handling of the medication card, led to the determination of narcotic diversion and misappropriation of resident property.
Resident Dignity Compromised Due to Inadequate Clothing
Penalty
Summary
The facility failed to ensure the dignity of a resident by allowing her to sit in a public area with a private body part exposed. On the specified date, Resident #85 was observed sitting in a reclined wheelchair near the centralized nurse's station with her tank top having fallen from her left shoulder, exposing her breast. This occurred in the presence of approximately ten other residents, staff, and visitors. Licensed Practical Nurse (LPN) #1, who was responsible for the resident, acknowledged the issue and attempted to cover the resident with a fleece blanket, admitting that she should have provided the resident with different clothing. Further investigation revealed that the resident's closet contained appropriate clothing options, including shirts with sleeves and a robe. Certified Nurse Assistant (CNA) #2 confirmed that the resident should have been dressed in clothes that fit properly to maintain her dignity. The Director of Nurses (DON) also confirmed that the resident's exposure was a dignity issue and that residents should be dressed to prevent exposure of private body parts. Resident #85 had been admitted to the facility with a medical diagnosis of Senile Degeneration of Brain.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement comprehensive person-centered care plans for three residents, leading to deficiencies in their care. Resident #20, who was admitted with hemiplegia following a nontraumatic intracerebral hemorrhage, was observed with unshaven facial hair and soiled clothing, indicating that the care plan for activities of daily living (ADLs) was not followed. The Director of Nursing confirmed the importance of adhering to the care plan to provide necessary care. Similarly, Resident #44, who requires assistance with ADLs due to muscle weakness and cognitive impairment, was observed with food stains on her clothing, suggesting that staff did not follow the care plan to ensure the resident was cleaned after meals. Additionally, the facility failed to develop a care plan for Resident #68's left-hand splint, which was ordered by a physician to prevent worsening joint deformity. The splint was not listed in the resident's care plans or the electronic care guide, and staff interviews confirmed that the splinting device was not included in the care plan after the resident was discharged from occupational therapy. This oversight was acknowledged by the Director of Nursing and the Minimum Data Set Coordinator, who confirmed that the care plan should have been updated to reflect the resident's specific needs.
Failure to Assist Residents with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents who were dependent on staff for personal care. Resident #20 was observed with unshaven facial hair and wearing visibly soiled clothing, which included a hospital gown with a tan-colored liquid and pieces of carrot on it. Despite the facility's policy that residents unable to perform ADLs independently should receive necessary services, the staff overlooked these needs. Interviews with the RN and DON confirmed that aides were responsible for shaving female residents and changing soiled clothing, but these tasks were not completed for Resident #20. Similarly, Resident #44, who was dependent on staff for feeding, was observed with food remnants on her clothing after lunch. The CNA and LPN interviews confirmed that Resident #44 required assistance with eating and should have been cleaned up after meals. The DON acknowledged that Resident #44 typically wore a bib and should have been checked and cleaned before leaving the dining area. The facility's failure to adhere to its policy resulted in inadequate care for these residents, as evidenced by the observations and staff interviews.
Failure to Maintain Resident's Range of Motion Due to Missing Splint Order
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve the range of motion (ROM) for a resident, leading to a deficiency. The resident, who has a history of cerebral palsy and hemiplegia, was observed with a contracted left hand/wrist and a splinting device lying unused on the counter. Despite the resident's severe cognitive impairment, the splint was not applied as required. Interviews with staff, including an LPN and the occupational therapist, confirmed that the resident should have been wearing the splint to prevent worsening of contractures. However, the LPN did not verify the resident's use of the splint, and the occupational therapist had not discontinued the device. Further investigation revealed that the order for the left-hand splint was initially entered into the computer system when the resident was discharged from occupational therapy in February 2022. However, the order was inadvertently removed from the system in May 2022 and was not re-entered. The restorative nurse and the director of nursing confirmed the absence of the splint order in the current records, indicating a lapse in the facility's system to ensure the resident's ROM was maintained as per the physician's order.
Failure to Properly Clean and Store PEG Tube Syringe
Penalty
Summary
The facility failed to adhere to its infection prevention and control program by not properly cleansing and storing a Percutaneous Endoscopic Gastrostomy (PEG) tube syringe for one of the residents. During an observation, it was noted that the PEG tube syringe was left separated and lying on the bedside table without a clean barrier or storage bag, contrary to the facility's policy. The policy requires that syringes be dated, stored on a pole bag, and separated after use to prevent contamination with body fluids and possible transmission of infectious agents. Interviews with the Licensed Practical Nurse (LPN) assigned to the resident and the Infection Control Nurse confirmed the oversight. The LPN admitted to leaving the syringe on the bedside table and acknowledged that it should have been cleaned, dried, and stored in a clean storage bag. The Infection Control Nurse reiterated that the failure to clean and store the syringe appropriately increased the risk of infection transmission to the resident's gastric site. The resident, who was admitted with diagnoses including Cerebral Palsy and required all medications, nutrition, and fluids via the PEG tube, was thus placed at increased risk due to this oversight.
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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 Canton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkway Health & Rehab Llc | 4.8 mi | ★★★★★ | 4 | 0 |
| The Nichols Center | 10.2 mi | ★★★★★ | 5 | 0 |
| The Madison Health And Rehab | 11.9 mi | ★★★★★ | 4 | 0 |
| Highland Home | 15.8 mi | ★★★★★ | 1 | 1 |
| Community Place | 16.3 mi | ★★★★★ | 1 | 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.