Madison Health Care

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain its dumpster area in a clean and sanitary manner, which had the potential to affect all 102 residents residing in the facility. During an observation of the dumpster area, it was noted that two lids on one of the two dumpsters were not closed. Specifically, the top lid was open, and the side door was open with cardboard boxes hanging out. This condition was verified through an interview with the Dietary Manager at the time of the observation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a safe, sanitary, and comfortable environment for its residents, staff, and the public. Observations during a survey revealed multiple deficiencies in the cleanliness and maintenance of resident rooms and common areas. Cobwebs with insects were found in several residents' rooms, and windowsills were observed to be rotting and moist, indicating water damage. Bathrooms shared by residents had accumulations of dark substances around toilets and sticky floors with strong odors, suggesting inadequate cleaning. Additionally, light fixtures were found to contain numerous dead insects, and some rooms had holes in the walls covered with tape. The facility was also found to be understaffed in the housekeeping department, with a lack of a housekeeping supervisor for nearly three months. Interviews with staff confirmed that the facility was operating with fewer housekeepers than required, leading to incomplete cleaning tasks, including deep cleaning of residents' rooms. The housekeeping staffing schedule showed multiple days with only one or two housekeepers on duty, and documentation revealed that some rooms had not been deep cleaned for over two months. Furthermore, the main dining room had an active ceiling leak, with water dripping into a bucket, and the parking lot was poorly lit due to a broken light pole. The facility had been aware of these issues for several months but had not completed necessary repairs. Interviews with maintenance staff and administrators confirmed the ongoing nature of these problems and the lack of progress in addressing them. The facility's policy on maintaining a safe and sanitary environment was not being followed, contributing to the deficiencies observed during the survey.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide individual designated closet space for residents, affecting three residents directly and potentially impacting three additional residents. The deficiency was identified through record review, observation, and interviews. Resident #17, diagnosed with bipolar disorder, paranoid personality disorder, and schizophrenia, expressed dissatisfaction with his roommate wearing his clothes due to the lack of dividers in the shared closet. The closet was shared by three residents, and clothing was hung randomly without any indication of ownership, leading to confusion and mix-ups. Resident #18, with major depression, anxiety disorder, schizoaffective disorder, and bipolar disorder, confirmed that he sometimes wore his roommate's clothing as he could not identify his own due to the absence of dividers. Similarly, Resident #81, diagnosed with adjustment disorder, major depression, and psychosis, reported that the closet was too small and lacked dividers, making it difficult to store his clothes. The facility's policy required providing each resident with a private closet space, but this was not adhered to, as verified by the Administrator and Unit Manager/LPN during their interview.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident, identified as Resident #71, had a physician's order for the application and maintenance of a brace/splint on his left hand. Resident #71 was admitted with multiple wrist fractures and had refused occupational therapy but agreed to wear a splint. Despite this, there were no documented orders regarding the duration or guidelines for wearing the splint. The resident had impaired cognition and was independent with dressing but required setup help for personal hygiene. Nursing notes indicated that the resident continued to wear the splint since admission and refused to remove it, but there was no further documentation regarding the brace/splint in the care plan or physician's orders. Interviews with staff, including a CNA and a Unit Manager, confirmed that the resident wore the brace/splint continuously and refused to allow staff to remove it. The staff were unaware of any orders regarding the brace/splint, including its duration of use, and there was no documentation of monitoring for skin integrity or circulation under the brace. The facility's policy on the prevention of decline in range of motion required care plan interventions to be documented, but there was no mention of ensuring a physician's order for the splint. This oversight had the potential to affect other residents identified as using a brace/splint.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that preventative measures were in place for a resident identified as a fall risk, leading to a deficiency in care. The resident, who had a history of repeated falls and severe cognitive impairment, was observed without necessary fall prevention interventions. These interventions included having the call light within reach, the wheelchair at the bedside with brakes locked, and wearing non-skid socks. On multiple occasions, the resident was found in bed yelling for help with the call light out of reach, the wheelchair missing, and non-skid socks not in place. Staff interviews confirmed the resident's high fall risk and the absence of required interventions. The facility's policy on fall prevention and management was not implemented effectively, as evidenced by the resident's unmet needs and the staff's inability to locate the resident's wheelchair, which was found in the shower room. Despite having a care plan and physician orders detailing specific interventions to prevent falls, these measures were not consistently applied, resulting in the resident being left unattended and at risk for falls. The facility's failure to adhere to its own policy and the prescribed interventions contributed to the deficiency identified during the survey.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate respiratory care for Resident #89, who was admitted with diagnoses including dementia, acute respiratory failure with hypoxia, and was receiving hospice care. The resident had a physician's order for oxygen to be administered at two to ten liters per minute per nasal cannula to maintain pulse oximetry, but there were no parameters for titration or specific oxygenation levels to be maintained. Observations revealed that the resident's nasal cannula was not positioned correctly, and the oxygen delivery system was not a high flow nasal cannula as required for higher flow rates. The facility's records showed a lack of documentation regarding the resident's oxygen saturation levels and the effectiveness of the oxygen therapy. Additionally, the facility did not ensure proper signage indicating oxygen use for Residents #7 and #81. Resident #7, with diagnoses including morbid obesity and respiratory failure, had an order for continuous oxygen but lacked signage on the room door indicating oxygen was in use. Similarly, Resident #81, with chronic obstructive pulmonary disease and chronic respiratory failure, also had an order for continuous oxygen but no signage on the room door. Observations confirmed the absence of required oxygen warning signs, which was verified by the facility's Administrator and Unit Manager. The facility's policy on oxygen administration required documentation of the resident's condition and response to oxygen therapy, as well as the placement of oxygen warning signs on the doors of rooms where oxygen was in use. The failure to adhere to these policies affected three residents directly and had the potential to impact an additional 22 residents identified by the facility as using oxygen. The facility census was 102 at the time of the survey.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was free from significant medication errors. Resident #95, who had diagnoses including chronic obstructive pulmonary disease, dysphagia, hypertension, and acute respiratory failure with hypoxia, was receiving nutrition and medications through a PEG tube. The resident's care plan indicated that medications should be administered per physician order, but there was no order to crush and mix all medications together. During an observation, an LPN was seen administering multiple medications by crushing them together and mixing them with liquid supplements before administering them through the resident's PEG tube. This was done without a physician's order to cocktail the medications. Interviews with the LPN and the Director of Nursing confirmed that there was no order to mix the medications, and the facility lacked a policy regarding the administration of medications through a PEG tube. The facility's existing policies on medication administration and feeding tubes did not address the practice of cocktailing medications. The Director of Nursing acknowledged that medications should not be crushed and mixed together due to potential interactions, and that each medication should be administered separately with flushing in between to prevent interactions.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an injury of unknown origin to the state agency for a resident, which is a violation of their policy on abuse, neglect, and exploitation. The resident, who had a history of self-harm and dementia, was admitted to the facility and later complained of right hip pain. An x-ray revealed a mildly displaced fracture of the right femoral neck, which was later determined to be a nondisplaced superior ramus fracture. Despite the resident's history and the nature of the injury, the facility did not report the incident to the Ohio Department of Health (ODH) or conduct a thorough investigation. Interviews with facility staff, including the LPN, DON, and Administrator, revealed a lack of awareness and action regarding the resident's injury. The LPN was unaware of any falls or investigations, and the DON, who was not employed at the time, had no knowledge of the incident. The Administrator, who was the abuse coordinator, did not report the injury to ODH, assuming it was pathological due to the resident's osteopenia. However, there was no clinical verification of this assumption, and no investigation was conducted to rule out other causes such as self-injury or abuse. The facility's failure to investigate and report the injury was further highlighted by the absence of documentation in the incident log and the lack of a self-reported incident (SRI). The previous DON and attending physician also confirmed that no investigation was conducted to determine the cause of the fracture. The facility's policy required them to investigate and report such incidents, but this was not implemented, leading to non-compliance with state regulations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to thoroughly investigate injuries of unknown origin for a resident, which affected the quality of care provided. The resident, who had a history of self-harm and dementia, was admitted to the facility and later complained of right hip pain. An x-ray revealed a mildly displaced fracture of the right femoral neck, which was later determined to be a nondisplaced superior ramus fracture. Despite the resident's history of self-injurious behavior, the facility did not conduct an investigation to determine the cause of the fracture or report it to the state agency as required by their abuse policy. Interviews with facility staff, including the LPN, DON, and Administrator, revealed a lack of awareness and action regarding the resident's injury. The LPN was unaware of any falls or investigations, and the DON, who was not employed at the time, could not provide information on the incident. The Administrator confirmed that no investigation was conducted to rule out an unwitnessed fall, self-injurious behavior, or abuse. The facility's failure to investigate and report the injury was a violation of their policy on abuse, neglect, and exploitation. The facility's documentation and interviews indicated that the injury was assumed to be a result of osteoporosis, without proper investigation. The attending physician noted that the fracture could have occurred from various causes, but no specific reason was determined due to the lack of investigation. The facility's incident log did not document any incidents related to the resident, further highlighting the deficiency in addressing the injury of unknown origin.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident, identified as Resident #103, resided in the least restrictive environment and was free from involuntary seclusion. Resident #103 was placed on a secured memory care unit despite being cognitively intact and competent to make her own decisions. The resident's medical records and progress notes did not provide sufficient evidence to justify her placement on the secured unit, as there were no documented behaviors such as yelling, screaming, verbal aggression, wandering, or medication non-compliance that would necessitate such a restrictive environment. Resident #103 had a history of schizoaffective disorder, bipolar type, and mild dementia with other behavioral disturbances. Despite these diagnoses, the resident was deemed competent and capable of making her own decisions, as confirmed by a statement of expert evaluation. The resident expressed her desire to leave the secured unit and was aware of her rights to make decisions regarding her care. However, the facility did not re-evaluate her need for secured unit placement after she was determined competent, and there was no documentation supporting the necessity of her continued confinement. Interviews with facility staff, including the Administrator and Social Worker Assistant, revealed that Resident #103's placement on the secured unit was initially influenced by her family's request and her past behaviors. However, staff acknowledged that there was no current evidence of behaviors that would justify her placement on the secured unit. The facility's policy required a diagnosis of dementia or other health conditions that would benefit from increased supervision, but Resident #103 did not exhibit behaviors that posed a risk to herself or others, nor did she have a history of elopement or exit-seeking behaviors.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement care planned interventions for a resident with an open area on the left buttock and posterior thigh. The resident, who was cognitively intact, had a history of type two diabetes mellitus, depression, bipolar disorder, schizoaffective disorder, and an acquired absence of the left upper limb below the elbow. The resident was dependent on staff for personal hygiene and was frequently incontinent. Despite these needs, the care plan interventions to inspect the skin condition daily and report any impaired areas were not followed, leading to the oversight of the resident's wound. During an observation, a Licensed Practical Nurse (LPN) and a Certified Nursing Assistant (CNA) discovered an open area on the resident's left buttock and thigh, which was covered with a foam dressing and barrier cream. The wound was approximately one and a half inches by a half inch, with surrounding tissue that was dark red and purple. The LPN and CNA confirmed that the wound was present during previous incontinence care, but there was no documentation or treatment orders for the wound prior to this observation. The facility's policy required therapeutic treatment for wounds to be implemented by a nurse with a physician's order, and wounds were to be evaluated and monitored regularly. However, the resident's wound was not assessed or treated according to these guidelines. The deficiency was identified during a complaint investigation, highlighting a failure to provide timely and appropriate care for the resident's skin integrity issues.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure effective fall interventions for Resident #10, who was at high risk for falls due to moderate intellectual disabilities, major depressive disorder, epilepsy, and unsteadiness on feet. Despite being provided with a helmet and encouraged to use non-skid footwear, Resident #10 was noncompliant with these safety measures and frequently attempted self-ambulation and transfers without assistance. The resident's care plan included reminders to use the call light for assistance, but these interventions were not consistently effective, as Resident #10 often refused to comply and experienced multiple falls, some resulting in injuries and fractures. Observations revealed that Resident #10 was often seen without a shoe or non-skid sock on his left foot, despite the facility's policy to encourage the use of non-slip footwear. Staff interviews indicated that Resident #10 was impulsive and valued his independence, which contributed to his noncompliance with safety interventions. The resident's room was located near the nurses' station to allow for closer supervision, but the call light was not always tied to the light cord as intended, further compromising the effectiveness of the fall prevention measures. The facility's incident log documented numerous witnessed and unwitnessed falls over the course of a year, highlighting the ongoing issue of inadequate fall prevention for Resident #10. Staff members, including CNAs and the DON, acknowledged the resident's high fall risk and the challenges in implementing effective interventions. Despite efforts to review and adjust the resident's care plan, the facility struggled to find successful strategies to prevent falls, resulting in a deficiency under Complaint Number OH00159658.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure appropriate supervision to prevent a resident from leaving the facility unattended without staff knowledge. This incident involved a resident with a history of traumatic brain injury, cognitive communication deficit, impulse disorder, and falls. The resident was at risk for elopement and had previously expressed a desire to leave the facility. On the day of the incident, the resident had pulled out their nasogastric tube and was scheduled to be transported to the hospital for replacement. However, the resident was last seen by staff at 9:00 P.M. and was later found outside the facility by a passerby. The passerby alerted the staff after observing the resident in a gown and wheelchair on the road in front of the facility. The staff initiated elopement procedures and called emergency services. The police were already en route to a nearby house where the resident had been reported by a homeowner. The staff located the resident at the residence and returned them to the facility without any noted injuries. The resident was then transported to the hospital for the scheduled procedure and placed on 1:1 supervision upon return. Interviews with the facility's Administrator and RN revealed that the resident was considered alert and oriented, although their mentation fluctuated due to their brain injury. The facility considered the event an unauthorized leave of absence. The RN on duty at the time of the incident had informed the resident of the upcoming hospital transport and denied their request to go outside to smoke. The resident's elopement was discovered when a woman entered the facility to report seeing the resident outside, prompting the staff to initiate a head count and elopement procedures.

Penalty

Inspection fine: $109,991

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary goods and services to prevent neglect, resulting in the death of a resident. The resident, who had a full code status, exhibited behaviors and requested a bronchodilator without further assessment or monitoring. Despite the resident's request for medication, there was no documented evidence of its administration or any follow-up assessment to determine its effectiveness. The resident was found deceased the following day, with rigor mortis indicating he had been dead for some time. The resident had a history of chronic obstructive pulmonary disease (COPD), schizophrenia, and other medical conditions. He had recently been readmitted from a psychiatric hospital stay for psychosis. Despite his complex medical history and recent behavioral issues, the facility staff failed to monitor his condition adequately. The resident's care plan included specific interventions for his COPD and behavioral issues, but these were not followed, leading to a lack of necessary care and monitoring. Interviews with staff revealed multiple failures in communication and care. The LPN on duty did not assess the resident's respiratory status or document the administration of the requested medication. The morning shift nurse assumed the resident was sleeping and did not attempt to administer medications or assess his condition. The resident was left unattended for several hours, during which time he passed away without receiving the necessary care and attention.

Removal Plan

• LPN #410 was educated on the medication administration policy.
• Education was provided to nine nurses in the center by the DON regarding Abuse/Neglect policy, Resident Care policy, Medication Administration policy, Notification of Change policy, Medical Emergency Response policy and Stop Watch protocol.
• Education was provided to 16 STNAs in the center by the DON regarding Abuse/Neglect, Resident Care policy, Medical Emergency Response policy and Stop and Watch policy.
• The Administrator, Regional Director of Clinical Services #459, and Regional Director of Operations #458 provided education to 20 nurses over the phone regarding Abuse/Neglect, Resident Care policy, Medication Administration policy, Notification of Change policy, Medical Emergency Response Policy and Stop and Watch protocol. All staff who were not contacted were removed from the schedule until education was provided.
• The administrator, Regional Director of Clinical Services #459, and Regional Director of Operations #458 provided education to 42 STNAs over the phone regarding Abuse/Neglect, Resident Care policy, Emergency Response policy and Stop and Watch protocol. All staff that could not be contacted were removed from the schedule until education could be provided.
• The facility conducted comprehensive assessment utilizing the Monthly Long Term Care Assessment (UDA) on all residents. This was completed by the DON, unit managers, or mobile DON.
• Medication Administration Records were reviewed by Regional Director of Clinical Services #459 in the facility regarding any medication that was not administered. Follow up completed as indicated.
• Medication Administration Records were reviewed by Regional Director of Clinical Services #459 for all residents in the facility regarding refusal of medication. Follow up completed as indicated.
• An Ad hoc Quality Assessment and Performance Improvement meeting was held. Staff in attendance at the meeting included the Administrator, the DON, Regional Director of Clinical Services #459, and Regional Director of Operations #458. The Medical Director was notified of the Immediate Jeopardy concern.
• The DON/Unit Manager/Designee completed observations with non-interviewable residents for concerns related to potential neglect. Any concerns would be addressed as indicated.
• The DON and Unit Managers met with interviewable residents regarding any resident concerns related to potential neglect. Any concerns were addressed as indicated.
• The facility implemented a plan to conduct ongoing monitoring/audits regarding completed medication administration documentation to ensure all residents received medication as ordered. A QAPI meeting would be held to determine if extension of medication administration documentation audits were indicated.
• The facility implemented a plan to conduct ongoing monitoring of progress note reviews for all residents in the facility for change in condition. Follow-up would be completed as indicated for change in condition. A QAPI meeting would be held to determine if extension of progress note review was indicated.
• The facility implemented a plan for ongoing monitoring/audits regarding comprehensive assessments for five residents utilizing the UDA for any change in condition. A QAPI meeting would be held to determine if extension of the comprehensive assessments was indicated.

Penalty

Inspection fine: $109,991

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that medications were administered per physician orders, resulting in a significant medication error for Resident #105. This resident, who had multiple diagnoses including schizophrenia and cognitive impairment, did not receive their prescribed morning medications on 05/25/24. The medications included Famotidine, Paliperidone Palmitate, Polyethylene Glycol, Carbamazepine, Klonopin, and Benztropine Mesylate, which were to be administered between 7:00 A.M. and 11:00 A.M. The failure occurred when LPN #339, upon finding the resident sleeping, decided not to administer the medications and did not return to attempt administration until after a Code Blue was called for the unresponsive resident at 12:30 P.M. Interviews and record reviews confirmed that the medications were not administered as ordered, and the MAR reflected this omission. The facility's policy required medications to be administered within the ordered time frames and for attempts to be made three times before notifying a physician if a resident does not take the medication. The deficiency was identified during a complaint investigation, highlighting a lapse in following the facility's medication administration policy.