Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Madison On Marsh during CMS and state inspections, most recent first.
Failure to Invite Residents and Representatives to Care Plan Meetings: The facility did not ensure that four residents were invited and given the opportunity to participate in care conferences for their person-centered plans of care. Records showed no documentation of written notices, phone calls, or attendance at care conferences, and several residents or family members stated they had never received an invitation or a copy of the care plan. Staff interviews confirmed that written notices were not sent and that meetings were sometimes held on an impromptu basis.
Failure to Employ a Full-Time Social Worker: The facility, licensed for 125 beds, did not have a full-time social worker on staff. The DON and Administrator stated the prior social worker had left, the position had been vacant for about three to four weeks, and the interdisciplinary team, including the Administrator, had been covering social worker duties such as referrals and care conferences. A staff roster review confirmed there was no social worker employed at the facility.
The facility failed to provide written transfer/discharge notices to two residents when they were sent to the hospital, and failed to send copies to the LTC Ombudsman. One resident had multiple serious diagnoses including GI bleed, tibia fracture, AFib, depression, anxiety, obesity, and polyneuropathy with moderate cognitive impairment; the other had UTI, weakness, dysphagia, HTN, and obesity with intact cognition. Interviews showed the DON believed Ombudsman notification was only needed for AMA or unsafe community discharges, and staff stated residents never received written transfer/discharge notices.
Care plans for two residents did not reflect updated DNR code status orders. One resident had severe cognitive impairment, multiple diagnoses, and a physician DNR order, but no advanced directive care plan was documented. Another resident with intact cognition had a DNR order, yet the care plan still listed full code. A third resident with severe cognitive impairment and multiple medical conditions also had a DNR order, but the care plan continued to show full code despite the completed OOH-DNR paperwork.
A resident with severe cognitive impairment, stroke, hemiplegia, and cancer was left in a highly elevated bed with the side rail down while CNA A left the room to get a Hoyer lift. The resident remained unattended until the CNA returned and lowered the bed; the DON stated staff were not allowed to leave a resident alone in an elevated bed with the positioning rail down.
A resident with a Foley catheter and severe cognitive impairment did not receive complete incontinence care when a CNA cleaned the peri-area and buttocks but left visible stool on the catheter tubing and peri-area before closing the brief. The CNA later recleaned the area after the surveyor intervened, and the DON confirmed staff were expected to clean the peri-area and catheter tubing during incontinence care.
A resident's bedroom wall next to the headboard had a large, dry red/tan spill that remained in place for at least a day or two. The resident had severely impaired cognition, stroke, hemiplegia, and cancer, and required moderate assistance for repositioning. A CNA did not know about the spill, and the Administrator identified it as red juice; staff were expected to notify housekeeping or get wall spills cleaned.
A resident was discharged without a complete discharge summary, as required by facility policy. Key sections of the discharge instruction form and recapitulation of stay were left incomplete and unsigned, and no discharge summary was uploaded to the EMR. Staff interviews confirmed that the nurse responsible did not follow procedures for copying and documenting discharge paperwork, resulting in missing information on follow-up care, medications, and services.
A resident with a recent surgical wound did not have wound care interventions included in their care plan, despite physician orders and ongoing wound care being provided. Staff interviews revealed confusion over responsibility for updating care plans, resulting in the omission of necessary wound care instructions from the resident's plan.
A resident with cognitive impairment and a history of exit-seeking behavior eloped from the facility by exiting through the front door without triggering the alarm system, remaining missing for several hours before being found nearly nine miles away. Staff failed to identify the resident's elopement risk, and routine monitoring and alarm systems were not effective in preventing the incident.
Surveyors found that multiple food items in the kitchen refrigerator were not labeled, dated, or covered as required by facility policy and professional standards. Staff interviews confirmed that all dietary staff were responsible for these tasks, but the procedures were not consistently followed, leading to a deficiency in food storage practices.
A resident with diabetes, muscle weakness, and severe cognitive impairment who required extensive assistance for ADLs was found with long, discolored fingernails containing residue. Although the care plan and facility policy required licensed nurses to trim the nails of diabetic residents and for nail care to be part of routine hygiene, staff failed to communicate and address the resident's nail care needs, resulting in unclean and untrimmed nails.
The facility failed to lock medication carts when not in use, as observed with four medication carts left unlocked in the hallway. LVN A left Medication Carts #1 and #2 unlocked while attending to residents, citing disorganization due to being new to the hall. Medication Carts #3 and #4 were also found unlocked with no staff present. Interviews confirmed that carts should be locked when not in eyesight, aligning with the facility's policy on medication storage.
A resident's privacy was compromised when a CNA left the door open and did not draw the privacy curtain while providing incontinent care, leaving the resident exposed to the hallway. The CNA admitted to rushing due to other duties, and while staff were aware of privacy protocols, the facility's policy did not address privacy rights.
The facility failed to ensure that comprehensive care plans for two residents were reviewed and revised by the interdisciplinary team after each assessment. One resident with heart failure and diabetes had a care plan not updated since September, while another resident with stroke and dementia had a care plan not updated since July. The Social Worker attributed the oversight to being busy, and the Administrator did not recognize any risk associated with the delay.
A resident with diabetes received insulin contrary to physician orders, as their blood sugar levels were below the threshold for administration. The facility's documentation failed to reflect this discrepancy, and interviews with staff revealed a lack of clarity and oversight in the medication administration process.
The facility failed to properly label and date food items in their kitchen, as observed during an inspection. Items in the walk-in refrigerator and dry storage were found without necessary labels or dates, contrary to the facility's policy and FDA guidelines. Staff interviews confirmed the risks of food-borne illnesses and serving expired foods due to these lapses.
The facility failed to update the care plans for two residents on hospice care, resulting in the absence of hospice-related goals and interventions. Both residents had severe cognitive impairments and were admitted to hospice services, but their care plans were not revised to reflect this change. The deficiency was due to the lack of a permanent MDS/care plan nurse, with temporary staff not updating care plans as required by facility policy.
The facility failed to maintain safe and clean wheelchairs for three residents, who were cognitively impaired and unable to make decisions for themselves. Observations showed cracked armrests and dried food on the wheelchairs, with no record of maintenance requests. Interviews revealed a lack of awareness and formal reporting system for repairs, with the DON admitting to no cleaning schedule and the Maintenance Director unaware of needed repairs.
Failure to Invite Residents and Representatives to Care Plan Meetings
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were invited and given the opportunity to participate in the development and implementation of the person-centered plan of care for 4 of 6 residents reviewed for resident rights. The deficiency involved Residents #2, #20, #27, and #73, and the record review showed no documentation of care conference invitations, phone calls, or letters notifying the resident or representative of the meeting time and date. The facility also had no documentation in the electronic medical record showing that these residents or their representatives attended a care conference or received a copy of the plan of care. Resident #2 was a female with diagnoses including acute gastrojejunal ulcer with hemorrhage, a nondisplaced transverse fracture of the left tibia, chronic atrial fibrillation, major depressive disorder, anxiety disorder, morbid obesity, and polyneuropathy. Her quarterly MDS showed a BIMS score of 10/15 and she required maximum to dependent assistance with care. During interview, she stated she had never received a letter or invitation for a care conference, had never attended a care conference with the DON, Administrator, DOR, Dietary, or Activities, and had never received a copy of her plan of care. Resident #20 was a male with diagnoses including osteomyelitis, type 2 diabetes, paraplegia, and obstructive and reflux uropathy. His admission MDS showed a BIMS score of 15/15 and he required partial to maximum assistance with care. He stated he talked to therapy and nursing when he first arrived, but there was no meeting with anyone else to discuss his care and he had never received a copy of his plan of care. Resident #27 had diagnoses including a left femur neck fracture, iron deficiency, moderate protein-calorie malnutrition, hyperlipidemia, essential hypertension, heart failure, muscle weakness, and chronic kidney disease. Her quarterly MDS showed a BIMS score of 3/15 and she required partial to maximum assistance with care. Her family member stated she had never received a letter, invitation, or phone call for a care conference, had never attended a care conference with the DON, Administrator, DOR, Dietary, or Activities, and had never received a copy of the plan of care. Resident #73 was a female with diagnoses including metabolic encephalopathy, muscle weakness, difficulty walking, dementia, schizoaffective disorder, generalized anxiety disorder, and bipolar disorder. Her quarterly MDS showed a BIMS score of 7/15 and she required mostly maximum assistance with care. Her family member stated she had never received a letter, invitation, or phone call for a care conference, had never attended a care conference with the DON, Administrator, DOR, Dietary, or Activities, and had never received a copy of the plan of care. Interviews with the Administrator, DON, DOR, MDS Coordinator, and other staff showed the facility conducted care conferences with residents and/or responsible parties, but written notices were not sent and meetings were sometimes held on an impromptu basis. The facility policy stated the comprehensive care plan would include the resident and the resident's representative to the extent practicable, along with other appropriate staff and professionals as determined by the resident's needs or as requested by the resident.
Failure to Employ a Full-Time Social Worker
Penalty
Summary
The facility failed to ensure that a facility with more than 120 beds employed a qualified social worker on a full-time basis. The facility was licensed for 125 beds, and record review of the daily census and the Facility Summary Report from TULIP confirmed the licensed bed capacity was 125. A review of the staff roster showed there was no social worker on staff. During interviews, the DON stated the previous social worker had left for better job opportunities and that the interdisciplinary team had been handling social worker duties, including sending referrals and conducting care conferences. The Administrator stated the facility did not have a social worker on staff and that the position had been vacant for approximately three to four weeks. He also stated he was responsible for hiring a full-time social worker but had not been successful in locating a licensed candidate. The DON further stated there was no corporate social worker assigned to the building, though a social worker from a sister facility could assist if needed, and there was no established schedule for those visits.
Failure to Provide Written Transfer/Discharge Notices and Ombudsman Notification
Penalty
Summary
The facility failed to provide written transfer or discharge notices, in a language and manner the residents could understand, before two residents were transferred to the hospital. The record review and interviews showed that Resident #2, a female with diagnoses including acute gastrojejunal ulcer with hemorrhage, nondisplaced transverse fracture of the left tibia, chronic atrial fibrillation, major depressive disorder, anxiety disorder, morbid obesity, and polyneuropathy, was sent to the emergency room for abdominal pain. Her quarterly MDS reflected a BIMS score of 10/15, indicating moderate cognitive impairment, and she required maximum to dependent assistance with care. Resident #12, a female with diagnoses including UTI, muscle weakness, difficulty walking, dysphagia, hyperlipidemia, essential hypertension, and morbid obesity, was also sent to the emergency room. Her admission MDS reflected a BIMS score of 14/15, indicating cognitively intact mental status, and she required moderate to maximum assistance with care. For both residents, the record review found no evidence that a transfer or discharge notice was provided in writing to the resident or representative, and no evidence that a copy was sent to the Office of the State LTC Ombudsman. During interviews, the DON stated the Ombudsman was only notified for residents leaving against medical advice or for unsafe community discharges, and later stated residents never received transfer or discharge notices in writing. The Regional Operations staff stated she had never heard of a requirement to provide a written notice when residents were discharged to the hospital with the intention of returning to the facility. The facility policy required written notice to the resident and representative, inclusion of appeal rights and Ombudsman contact information, and maintenance of evidence that notice was sent to the Ombudsman.
Care plans did not reflect DNR code status changes
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for residents whose code status changed from full code to DNR. For Resident #1, who had diagnoses including mild protein-calorie malnutrition, dysphagia, cognitive communication deficit, schizoaffective disorder, bipolar disorder, and anxiety, the record showed a BIMS score of 7/15 with severe cognitive impairment and dependence on staff for all ADLs. Although a physician DNR order was signed on 01/07/2026 and the facility's DNR binder contained a correctly completed OOH-DNR order, the resident's care plan, initiated on 01/01/2026, did not include a care plan for advanced directives. For Resident #11, the admission MDS reflected intact cognition with a BIMS score of 15 and a diagnosis of heart failure. The Order Summary Report showed a DNR order dated 01/12/26, but the care plan dated 01/10/26 still reflected that the resident requested full code status. The listed interventions were to inform staff of code status and monitor for decrease in change of condition, report to the physician, and notify the responsible party. For Resident #27, who had diagnoses including left femur neck fracture, iron deficiency, moderate protein-calorie malnutrition, hyperlipidemia, hypertension, heart failure, muscle weakness, and chronic kidney disease, the MDS showed a BIMS score of 3/15 and partial to maximum assistance with care. The physician order dated 02/11/2026 reflected DNR, and the DNR binder contained a correctly completed OOH-DNR order, but the care plan initiated on 02/10/2026 still stated the resident requested full code status. During interview, the resident's family member stated the resident had a signed DNR order that was given to the facility.
Resident Left Unsupervised in Elevated Bed
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices were used to prevent accidents for one resident who had severe cognitive impairment, stroke, hemiplegia, and cancer. The resident’s MDS reflected severely impaired cognitive skills for decision making, and the care plan identified a need for mechanical lift transfers with 2 staff assistance, as well as cueing, reorientation, and supervision as needed due to impaired cognitive function and risk for falls. During an observation, the resident’s bed was highly elevated in the air with the positioning side rail on the right side lowered, and CNA A was in the room. After the surveyor entered, CNA A left the room to get the Hoyer lift to transfer the resident. The resident remained in the elevated bed for 2-3 minutes until CNA A returned and lowered the bed and repositioned the side rail. CNA A stated it was not okay to leave the resident’s bed high in the air and leave the room, and the DON stated staff were not allowed to leave a resident alone in an elevated bed with the positioning rail down.
Failure to Clean Foley Catheter and Peri-Area During Incontinence Care
Penalty
Summary
The facility failed to ensure appropriate catheter and incontinence care for Resident #57, a severely cognitively impaired female with a Foley catheter and diagnoses including heart failure and obstructive uropathy. Her care plan identified a history of UTI and catheter presence, with an intervention to clean the peri-area with each incontinence episode. During observation, CNA B prepared to provide incontinence care, cleaned the peri-area and buttocks, and placed a clean brief, but visible bowel movement remained on the catheter tubing and peri-area before the brief was closed. When questioned by the surveyor, CNA B stated she had not seen the stool and then recleaned the peri-area, vaginal area, and Foley catheter tubing, removing a moderate amount of stool. In interview, CNA B stated she was supposed to clean the peri-area and catheter tubing during incontinence care and acknowledged that failing to do so could cause infection. The DON confirmed staff were supposed to clean the peri-area and catheter tubing during incontinence care and said staff were trained to do so. The DON also stated that failure to clean the peri-area and Foley catheter tubing could cause urinary tract infections. The facility policy for catheter care directed staff to wipe from front to back and to wipe the catheter with a new moist wipe or cloth.
Unclean Resident Room Wall
Penalty
Summary
The facility failed to ensure a safe, functional, sanitary, and comfortable environment for one resident when Resident #94's bedroom wall next to her headboard was observed with a large, dry, red/tan spill. Resident #94 was a [AGE]-year-old female admitted on [DATE] with severely impaired cognitive skills for decision making, a blank BIMs score, and diagnoses including stroke, hemiplegia, and cancer; she required moderate assistance for repositioning. During interview, the resident said she did not know how the spill got there and that it did not bother her. A CNA stated she did not know anything about the spill and said staff were supposed to notify housekeeping for spills on the wall. The Administrator later identified the substance as red juice and stated it may have been there for a day or two, and that staff were supposed to get wall spills cleaned. The facility policy stated it would provide a safe, clean, comfortable, and home-like environment.
Incomplete Discharge Summary and Documentation
Penalty
Summary
The facility failed to ensure the completion of a discharge summary, including a recapitulation of the resident's stay and final status at discharge, for one resident who was discharged to the community. Record review showed that the discharge instruction form and the IDT recapitulation of stay were incomplete and unsigned, with missing information in key areas such as follow-up appointments, dietary recommendations, skin issues, patient instructions, and multiple service sections. The only section completed was Social Services, and there was no discharge summary completed or uploaded in the resident's electronic medical record (EMR). Interviews with facility staff revealed that the nurse responsible for the discharge did not make a copy of the completed medication recapitulation, as the resident was in a rush to leave. The nurse acknowledged that she was supposed to make a copy and place it in the discharge paperwork tray for scanning into the EMR, and to create a progress note detailing the discharge. The nurse stated she had been trained on the discharge process and had not previously had issues, but failed to follow the procedure in this instance. The ADON and DON confirmed that each department was responsible for completing their section of the discharge summary and that the summary was not completed for this resident. The facility's policy required that the discharge summary include a recapitulation of the resident's stay, a final summary of the resident's status, and documentation of medication reconciliation. The policy also required that an evaluation of the resident's discharge needs, the post-discharge plan, and the discharge summary be filed in the resident's medical record. In this case, these requirements were not met, resulting in incomplete documentation for the resident's discharge.
Failure to Include Wound Care Interventions in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including a recent surgical wound. Despite physician orders specifying wound care instructions—such as allowing a PICO dressing to remain for one week, then removing it and notifying the physician with a photo of the underlying wound—these interventions were not incorporated into the resident's care plan. Record reviews confirmed that the care plan lacked focus, goals, and interventions related to wound care, even though the resident was at risk for pressure ulcers and required assistance with walking. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for updating care plans. The MDS Coordinator, ADON, and Wound Care Nurse each believed that others were responsible for ensuring wound care was included in the care plan. The Wound Care Nurse admitted to providing wound care without updating the care plan, citing oversight. The MDS Coordinator stated he could not update the care plan without information from the Wound Care Nurse, and the ADON acknowledged that the care plan should have been revised to reflect the wound care being provided. The facility's policy required baseline care plans to include initial goals based on admission orders and to be updated with necessary healthcare information. However, the lack of communication and clear assignment of responsibility resulted in the omission of wound care interventions from the resident's care plan. This failure was identified by the DON and Administrator, who confirmed that the care plan had not been updated to include the resident's wound care needs.
Resident Elopement Due to Inadequate Supervision and Alarm Failure
Penalty
Summary
A deficiency occurred when a resident with a history of cirrhosis, hepatic encephalopathy, restlessness, and agitation eloped from the facility and was missing for over five and a half hours before being found by a passerby nearly nine miles away. The resident had been assessed as having no elopement risk on a prior assessment, despite care plan documentation indicating potential for elopement and exit-seeking behaviors. The care plan included interventions such as frequent monitoring, activities, and room checks, but these measures were not effectively implemented to prevent the resident from leaving the facility undetected. On the night of the incident, the resident was last seen in the early morning hours and was able to exit through the front door by using the electric latch retraction. Camera footage confirmed the resident left the facility independently, dressed in street clothes and outdoor shoes. Staff interviews revealed that routine rounds were conducted every two hours, but the resident was not observed to be exit-seeking by some staff, and the door alarm did not alert staff to the resident's departure. There was confusion among staff regarding the functionality of the alarm system, with some reporting that the alarm was sensitive and would typically sound, while others noted that it did not activate on the night in question. The facility's documentation and interviews indicated that the alarm system was supposed to be engaged during nighttime hours and required a code to disarm. However, it was unclear how the resident was able to exit without triggering the alarm, and staff could not determine whether the alarm malfunctioned or if the resident had obtained the code. The lack of effective supervision and failure to ensure the alarm system functioned as intended directly contributed to the resident's ability to leave the facility without detection.
Failure to Properly Label, Date, and Cover Food Items in Kitchen Refrigerator
Penalty
Summary
Surveyors observed multiple food items in the facility's walk-in refrigerator that were not properly labeled, dated, or covered. Specific items included a plastic container with sausage, a container with red sauce, bags containing cooked brownies, bread slices with butter, cooked cornbread, Danish bread, a used block of cheese, cooked meat slices, and grated cheese. These items were found without appropriate labeling, dating, or covering, contrary to professional standards and facility policy. Staff interviews confirmed that all kitchen staff, including cooks, dietary aides, and the dietary manager, were responsible for ensuring food items were labeled, dated, and covered, and that failure to do so could result in cross contamination and potential illness. Review of facility policy and the FDA Food Code indicated that leftover and ready-to-eat foods must be stored in covered containers, clearly labeled and dated, and used within specified timeframes. The deficiency was identified through direct observation and staff interviews, which revealed that the required procedures for food storage were not consistently followed in the facility's only kitchen. No information was provided about specific residents affected or their medical conditions at the time of the deficiency.
Failure to Provide Necessary Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with a history of type 2 diabetes mellitus, muscle weakness, and cerebrovascular accident (CVA), who was severely cognitively impaired and required extensive two-person assistance for personal hygiene, was observed to have long, discolored fingernails with dark brown residue underneath. The resident's care plan specified that she depended on staff for all activities of daily living (ADLs), including nail care, and that licensed nurses were responsible for trimming the nails of diabetic residents. The care plan also included interventions for maintaining the resident's dignity by ensuring she was clean, dry, odor-free, and well-groomed. Despite these documented needs and interventions, staff interviews revealed a lack of communication and follow-through regarding the resident's nail care. CNAs stated they would notify a nurse about the need for nail care for diabetic residents, while the nurse interviewed was unaware of the resident's nail condition and had not been notified. The Director of Nursing confirmed that nail care should be performed as needed and during handwashing, with daily observation of nail condition. Facility policy also required that nail care be part of bathing and that nurses trim the nails of diabetic residents. The failure to provide necessary nail care resulted in the resident having long and dirty fingernails.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by professional principles. During an observation, Medication Carts #1 and #2 were found unlocked in the hallway while LVN A was in a resident's room. LVN A left the carts unlocked while attending to residents and even walked to the nurse's station, leaving the carts unattended. The drawers of these carts were accessible and contained routine medications. LVN A admitted to being aware of the requirement to lock the carts when not in eyesight but cited disorganization due to being new to the hall as a reason for the oversight. Further observations revealed that Medication Carts #3 and #4 were also left unlocked in the hallway with no staff or residents present. These carts remained unlocked for approximately 10 minutes. LVN B, who began her shift shortly after the observation, stated that the previous nurse should have ensured the carts were locked. Interviews with the Regional Director of Clinical Services and the Director of Nursing confirmed that medication carts are expected to be locked when not within the nursing staff's eyesight. The facility's policy, revised in February 2023, mandates that medications be stored in an orderly manner to prevent mixing and unauthorized access.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure personal privacy for a resident during care, as observed by surveyors. A CNA was assisting a resident with incontinent care without closing the door or drawing the privacy curtain, leaving the resident exposed to the hallway. The resident, an elderly female with a diagnosis including hypokalemia, was undressed from the waist down and turned on her side, visible from the hallway. The CNA admitted to not closing the door or curtain due to being rushed to prepare another resident for dialysis. Interviews with facility staff, including the CNA involved, the Administrator, and the Director of Nursing, confirmed awareness of the requirement to maintain privacy by closing doors and curtains during care. However, the Director of Nursing did not acknowledge any risk from the failure to ensure privacy, despite the Administrator recognizing the potential for privacy violations. The facility's policy on resident rights did not address privacy, contributing to the deficiency.
Failure to Update Comprehensive Care Plans Timely
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for two residents were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive assessment and quarterly review assessments. Resident #1, a cognitively intact female with acute chronic diastolic heart failure, type 2 diabetes, and high blood pressure, had a care plan that was not updated since the last care plan conference held on 09/18/2024. Similarly, Resident #2, a female with a history of stroke and dementia, had a care plan that had not been updated since 07/16/2024. This lack of timely updates to the care plans could affect residents by placing them at risk for not having their individual needs met. Interviews with the Social Worker and the Administrator revealed that care plans were supposed to be completed within 48 hours of admission and updated quarterly. However, the Social Worker admitted to being unsure of the risks associated with not updating care plans quarterly and attributed the oversight to being busy with other tasks. The Administrator acknowledged the Social Worker's responsibility for ensuring timely completion of care plans but did not recognize any risk associated with the delay. The facility's policy, revised in September 2010, mandates that the interdisciplinary team must review and update the care plan at least quarterly.
Failure in Medication Administration and Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medication for a resident diagnosed with diabetes and high blood pressure. The resident's care plan required insulin administration according to specific physician orders, which included not administering insulin if the blood sugar level was equal to or less than 110. However, on two occasions, the resident's blood sugar levels were recorded as 86 and 96, yet insulin was administered by an LVN, contrary to the physician's orders. This discrepancy was not documented in the non-PRN medication notes, leading to uncertainty about whether the medication was administered correctly. Interviews with the Director of Nursing and the Administrator revealed a lack of clarity and oversight regarding the medication administration process. The Director of Nursing was unsure if the medication was given as per the orders, and the Administrator could not explain why the MAR indicated that the medication was administered when it should not have been. The Regional Director of Clinical Services confirmed that the non-PRN medication notes did not document the non-administration of insulin on the specified dates, highlighting a failure in the facility's documentation and medication administration procedures.
Failure to Properly Label and Date Food Items
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their only kitchen. During an inspection of the walk-in refrigerator, several food items were found without proper labeling or dating. Specifically, a large zip-top bag of lettuce lacked both a received date and an expiration date. Additionally, a large container of unidentified food sauce and another of yellow dessert were dated but lacked label descriptions. In the dry storage area, a 10lb bag of potatoes was opened without any received or expiration date. Interviews with staff members, including DM and DA B, revealed that the facility's policy requires all food items stored in the refrigerator, freezer, or dry storage to be labeled and dated. Both staff members acknowledged the risks associated with not following these procedures, such as the potential for food-borne illnesses and serving expired foods to residents. The facility's Food Receiving and Storage Policy and the U.S. FDA Food Code 2022 were reviewed, highlighting the necessity for proper labeling and dating to ensure food safety and prevent contamination.
Failure to Update Hospice Care Plans for Residents
Penalty
Summary
The facility failed to review and revise the person-centered comprehensive care plans to reflect the current status of two residents who were on hospice care. Resident #37, a female with severe cognitive impairment and multiple diagnoses including dementia, hypertension, and diabetes, was admitted to hospice services. However, her care plan, last updated on 09/30/2024, did not include goals and interventions for hospice care. Similarly, Resident #50, also with severe cognitive impairment and diagnoses of hypertension and dementia, was admitted to hospice services, but her care plan, last updated on 09/10/2024, lacked hospice-related goals and interventions. The deficiency was attributed to the absence of a permanent MDS/care plan nurse, with the role being temporarily filled by a floating nurse who completed MDS assessments but did not update care plans. The Director of Nursing (DON) and Assistant Directors of Nursing (ADONs) were responsible for updating care plans, but acknowledged that some plans, including those for Residents #37 and #50, were not appropriately updated. The facility's policy requires care plans to be revised when there is a significant change in a resident's condition, which was not adhered to in these cases.
Failure to Maintain Safe Wheelchairs
Penalty
Summary
The facility failed to ensure that assistive devices, specifically wheelchairs, were maintained and free of hazards for three residents. Observations revealed that the wheelchairs of these residents had cracked armrests with exposed foam and were dirty with dried food substances. These residents were cognitively severely impaired and unable to make decisions for themselves, relying on the facility for their care and safety. Despite the visible damage and lack of cleanliness, there was no record of these issues being reported for maintenance or repair. Interviews with staff, including the Maintenance Director and the Director of Nursing (DON), indicated a lack of awareness and a formal system for reporting and addressing wheelchair maintenance issues. The DON admitted there was no cleaning schedule for wheelchairs, and cleaning was done on an as-needed basis. The Maintenance Director confirmed that repairs were logged in a book at the nurse's station, but no entries for wheelchair repairs were found. The Administrator was also unaware of the need for repairs, despite having the necessary parts available.
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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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Illustrative
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Nursing homes near Carrollton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Gardens Rehabilitation And Healthcare | 3 mi | ★★★★★ | 10 | 0 |
| Carrollton Health And Rehabilitation Center | 3 mi | ★★★★★ | 27 | 0 |
| Signature Pointe | 3.4 mi | ★★★★★ | 29 | 0 |
| Treemont Healthcare And Rehabilitation Center | 4.1 mi | ★★★★★ | 5 | 2 |
| Brentwood Place Three | 4.2 mi | ★★★★★ | 14 | 1 |
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