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 October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Madison Medical Resort during CMS and state inspections, most recent first.
PEG Tube Feeding Care and Labeling Deficiencies: A resident with a PEG tube was observed in a compromised position below the ordered head-of-bed elevation, and two other residents with tube feedings had unlabeled and undated enteral feeding bags. The record showed one resident had aspiration pneumonia and another had severe cognitive impairment, while staff interviews confirmed the bags were supposed to be labeled with resident and order information and residents on continuous feeds were expected to remain upright.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect: The facility did not fully document or complete thorough investigations into two allegations involving a resident who reported being hit during incontinent care and another resident who was reportedly left soiled on the toilet. The reports included statements from the CNA, RN, and hallway safety surveys, but lacked documented interviews with the affected residents, resident representatives, and other key personnel, and the Administrator acknowledged the investigations were not thoroughly documented.
Incomplete Person-Centered Care Plans With Non-Measurable Goals: The facility failed to develop comprehensive, person-centered care plans for multiple residents with assessed needs such as cognitive impairment, ADL dependence, pain, dehydration, infection risk, side rail use, and chronic conditions including DM, HTN, GERD, depression, anxiety, edema, and use of high-risk meds. The care plans used broad goals like "will remain free" or "will not experience" without measurable objectives or clear timeframes.
Kitchen Food Storage and Sanitation Deficiencies: The kitchen had dirty floors with food particles, grease, dust, and dried residue, including buildup behind the warmer oven, in dry storage, the walk-in refrigerator/freezer, and the dishwasher room. Staff also left open-to-air food items in dry storage and the refrigerator, and several opened sauce bottles were stored without refrigeration despite manufacturer instructions. Interviews showed staff and leadership expected items to be dated, labeled, covered, and cleaned per schedule, but the DM reported missing sign-offs, lack of oversight, and no in-services or competencies for storage, labeling, or cleaning.
Two residents requiring enhanced barrier precautions (EBP) due to catheters and wounds did not receive proper care as CNAs failed to don gowns and gloves during incontinent care and transfers. The facility's policy on EBP was not followed, leading to potential cross-contamination risks.
A resident's privacy was compromised when a CNA failed to close the window blinds while providing incontinent care, exposing the resident to passersby. The resident, who was cognitively impaired, was unaware of the breach but stated she would feel embarrassed if exposed. The CNA acknowledged the oversight, and the facility's policy mandates closing blinds to ensure privacy.
The facility failed to post 'Oxygen in Use' signage for two residents receiving oxygen therapy, despite their medical conditions requiring such care. Both residents had specific orders for oxygen therapy, yet observations revealed the absence of necessary signage on their doorways. The DON acknowledged the oversight and noted that no training had been conducted to ensure compliance.
PEG Tube Feeding Care and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure appropriate care for residents receiving PEG tube feedings, including maintaining proper positioning and correctly labeling enteral feeding bags. Resident #3 had a feeding tube on admission, was dependent for multiple mobility tasks, and had diagnoses including COPD, cerebellar stroke, elevated troponin likely type II demand ischemia, and aspiration pneumonia. The care plan directed that the head of bed be elevated to 45 degrees during and after tube feeding. During observation, the resident was seen on continuous PEG tube feeding with the enteral feeding and hydration bags dated 07/20/2026 at 3:30 a.m., while the resident was resting at a 30-degree angle and leaning to the right with her head below chest level. A later observation found the resident again in a compromised position, sinking in bed to a flat position with knees to chest until staff corrected it after it was brought to attention. Resident #9 had a feeding tube, was cognitively intact, and had diagnoses including myopathy, malnutrition, parotid gland tumor, thyroid cancer, and chronic dysphagia. During observation, she stated she had difficulty communicating due to throat cancer and was coughing with difficulty breathing from phlegm and saliva in her mouth while on NPO orders. Her enteral feeding bag and hydration bag were observed to be unlabeled, and she stated she could not recall when the facility had changed her feeding bag. Resident #10 had severe cognitive impairment, required substantial to maximal assistance with mobility, and had a feeding tube. The care plan directed that the head of bed remain at a 45-degree angle while receiving continuous feedings. During observation, the resident was resting in a geriatric chair at a 30-degree angle for PEG tube feeding, and the enteral feeding bag and hydration bag were both undated and unlabeled. Interviews with nursing staff and leadership confirmed that enteral feeding bags were expected to be labeled with the resident name, date, time, formula, rate, and additives, and that residents with tube feedings needed to remain upright to reduce aspiration concerns.
Failure to Thoroughly Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate two self-reported allegations involving abuse and neglect. For one resident, who had moderate cognitive impairment, Parkinsonism, frequent bowel and bladder incontinence, and required assistance with toileting hygiene and personal care, the allegation was that a CNA hit his foot during incontinent care. For another resident, who had severe cognitive impairment, required substantial assistance with transfers and toileting hygiene, and had diagnoses including myopathy and rhabdomyolysis, the allegation was that the same CNA left him soiled on the toilet. For the first allegation, the provider investigation report included a written statement from the CNA and safety surveys from residents in the hallway, but no documented interviews or attempts to interview the resident were included in the report. The investigation summary stated that the resident later said nothing happened and referenced his paranoia and major depressive disorder. The report also noted that police were contacted, but it did not include the detailed investigative documentation described by facility staff as necessary for a thorough investigation. For the second allegation, the provider investigation report included a written statement from the CNA, written statements from the reporting RN, and safety surveys from residents in the hallway. The report summary stated that the issue appeared to be employee conflict and that after interviewing residents, no one had issues with the CNA, but the report did not contain documented interviews with residents or resident representatives. The report also did not include detailed documentation of interviews conducted with key personnel, what records were reviewed, or what the facility did to address or prevent further incidents. During interviews, facility staff and the Administrator acknowledged that the investigations lacked documentation of interviews, attempts to interview key individuals, and other details needed to show the investigations were thorough.
Incomplete Person-Centered Care Plans With Non-Measurable Goals
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for 10 of 10 residents reviewed. The deficiency involved residents with a wide range of assessed needs, including infection risk, injury/immobility related to quarter or half side rails, long-term care discharge planning, ADL assistance needs, limited range of motion, cognitive impairment, behavior problems, dehydration, pain, and multiple chronic diagnoses such as hypertension, diabetes, hyperlipidemia, hypothyroidism, GERD, depression, anxiety, edema, and use of high-risk medications. For Resident #5, the record showed diagnoses including left femur fracture after orthopedic aftercare, dementia, depression, hyperlipidemia, and dysarthria following cerebral infarction. The care plan included goals such as preventing injury from side rails, avoiding infection, maintaining function, addressing short-term memory problems, hypertension, edema, dehydration risk, hypothyroidism, anticoagulant therapy, antidepressant therapy, anti-anxiety therapy, and opioid use, but the objectives were written in broad terms such as "will not experience" or "will remain free" and did not provide measurable, verifiable outcomes. Similar care plan language was identified for Resident #6, Resident #12, Resident #44, Resident #58, Resident #61, Resident #65, Resident #100, Resident #113, and Resident #133. The records for the remaining residents showed comparable patterns of incomplete care planning. Examples included residents with severe or moderate cognitive impairment, multiple sclerosis, myopathy, heart failure, diabetes, bradycardia, dementia, communication problems, limited mobility, edema, dehydration, and use of antidepressants, antianxiety medications, opioids, diuretics, anticoagulants, and supplements. In each reviewed record, the care plans listed numerous problem areas and goals, but the objectives lacked measurable criteria, specific timeframes, or clearly defined outcomes tied to the residents' assessed needs.
Kitchen Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, and distribute food in accordance with professional standards in the kitchen area reviewed. During observation, the kitchen floors were dirty with food particles, a white dried substance, and a greasy film. The wall and floor behind the warmer oven were covered in grease and dust buildup with a white dried substance present. In the dry storage area, food particles were observed on the floor and under shelves, with dust buildup in the corners. In dry storage, a cardboard box lined with a plastic bag contained approximately 15 large white tea bags that were open to air. Also observed were one plastic bottle of caramel sauce with an open date of 3/5/2026, one plastic bottle of caramel sauce with an open date of 3/24/26, and one bottle of chocolate sauce with an open date of 3/24/26. The sauce bottles had manufacturer instructions to refrigerate after opening. In the walk-in refrigerator, a large clear plastic zip lock bag was open with a large bag of shredded cheese exposed to air, and dust buildup was present under the storage shelves. In the freezer section, several brown and clear pieces of wrappers were under the storage shelf along with dust buildup and little white pieces of an unknown substance. The dishwasher room floor also had dust buildup in the corner beside the dishwasher along with pieces of white and pink sugar packets. On follow-up observation, dust buildup and food particles remained on the dry storage floor, plastic wrappers and dirt buildup remained under the freezer shelves, and dust buildup with pieces of pink and white sugar packets remained on the dishwasher room floor. Interviews with kitchen staff and leadership confirmed that cleaning and storage tasks were expected to be completed according to schedules and policies, but the DM stated the March monthly cleaning schedules were not signed, the second shift did not initial the daily schedule for the week, and there had been a lack of oversight. The DM also stated she had not done in-services, trainings, or competencies for employees regarding storage, labeling, or cleaning.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNAs D and E during incontinent care for Resident #55, and CNAs B and C during a transfer for Resident #207. Resident #55, a female with diagnoses including muscle weakness, hypertension, and pneumonia, required enhanced barrier precautions (EBP) due to an indwelling catheter and incontinence. During an observation, CNAs D and E did not don the required EBP, which includes gowns and gloves, before providing care. Both CNAs acknowledged their failure to use EBP, citing reasons such as being in a rush and forgetting, which they recognized could lead to cross-contamination. Similarly, Resident #207, a male with acute kidney failure, urinary tract infection, and dementia, also required EBP due to an indwelling catheter and an unstageable pressure wound. During a mechanical lift transfer, CNAs B and C did not use EBP, as they were informed it was unnecessary for transfers. The Director of Nursing (DON) later acknowledged the oversight, understanding that not wearing EBP during transfers could pose a risk of cross-contamination. The facility's policy on EBP, which requires the use of gowns and gloves during high-contact activities, was not adhered to in these instances.
Privacy Breach During Incontinent Care
Penalty
Summary
The facility failed to ensure the personal privacy of a resident during the provision of incontinent care. A Certified Nursing Assistant (CNA) was observed performing perineal care on a resident without closing the window blinds, which exposed the resident to the view of people passing by outside the facility. This incident was observed by a state surveyor from the parking lot, a high-traffic area, where several people were walking by. The resident, who was severely cognitively impaired with a BIMS score of 06, was not aware of the privacy breach at the time but expressed that she would feel embarrassed if she knew she was exposed. The CNA admitted to forgetting to close the blinds during the care, despite being aware of the facility's policy requiring the closure of doors, privacy curtains, and blinds during such procedures. The Director of Nursing (DON) and the Administrator confirmed that the expectation was for staff to ensure privacy by closing the blinds, especially for residents in beds near windows. The facility's policy on perineal care also explicitly stated the need to provide privacy by closing the door, pulling the curtain, and closing the blinds.
Failure to Post Oxygen Signage for Residents Receiving Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, as observed by the absence of 'Oxygen in Use' signage on their doorways. Resident #61, a cognitively intact male with conditions including diabetes, dementia, and pleural effusion, was admitted with orders for oxygen therapy due to shortness of breath. Despite these orders, observations on multiple occasions revealed that there was no oxygen signage on his door, which is a requirement according to the facility's policy. Similarly, Resident #253, a female with diagnoses such as pulmonary edema and respiratory failure, was also receiving continuous oxygen therapy. Her care plan indicated the need for oxygen due to altered respiratory status. However, observations over several days showed that her room also lacked the necessary oxygen signage. The Director of Nursing acknowledged that all staff, including management, were responsible for ensuring the signage was posted, but admitted that no training or in-services had been conducted to address this requirement.
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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 Odessa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Deerings Nursing And Rehabilitation | 0.9 mi | ★★★★★ | 14 | 0 |
| Buena Vida Nursing & Rehab Odessa | 1 mi | ★★★★★ | 2 | 0 |
| Parks Health Center | 3 mi | ★★★★★ | 10 | 0 |
| Focused Care At Odessa | 5 mi | ★★★★★ | 12 | 0 |
| Sienna Nursing And Rehabilitation | 5.5 mi | ★★★★★ | 24 | 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 October 2026) and official state health department websites.