Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Madison, The during CMS and state inspections, most recent first.
A resident with documented decision-making capacity had a POST and care plan specifying full code status and full interventions, including CPR and life-sustaining treatments. As the resident’s condition declined, with increasing weakness, poor intake, low blood pressure, and a nonhealing coccyx wound, the PA reconfirmed that the resident understood her prognosis and still chose to remain full code with heroic measures. Later, when the resident became unresponsive with abnormal vital signs and respiratory difficulty, staff and the physician attempted to reach the resident’s son to change the POST to DNR instead of immediately implementing the existing full code orders, and they continued to monitor and document rather than initiate full interventions until the family reported the resident was unresponsive, at which point an LPN began CPR and EMS took over. In interview, the DON and ADON acknowledged they knew the POST specified full code and that the resident’s directive was not followed.
Unsanitary Conditions in Resident Rooms and Bathrooms: Surveyors observed brownish and dark red smears on toilet handrails, sticky yellowish residue on a wall behind a bed, dusty buildup on a hand sanitizer dispenser, blackish substance around a toilet base, cobwebs, and hair and dust under a sink in multiple resident rooms and bathrooms. A second walkthrough found the conditions had not been resolved, and the Corporate RN and Administrator acknowledged the findings.
Food was improperly stored and handled in the kitchen. Surveyors observed opened frozen food boxes and an open spice container left exposed to air, utensils scattered in the drawer, and two kitchen employees failing to wash hands or change gloves after touching surfaces and moving a tray cart during tray line prep. The Kitchen Mgr and corporate Kitchen Mgr acknowledged the storage and hand hygiene issues.
A resident was observed lying on a bariatric mattress placed on a standard bed frame, with about 12 inches of the mattress hanging over the frame and leaving an unsupported area. The DON verified the mattress was too large for the frame and stated it should not be larger than the frame.
Incomplete Daily Nursing Staff Posting: The facility failed to ensure the daily nursing staff form was accurate and complete. The daily census was missing from the posted staffing form on multiple days, and the DON concurred that the nurse staff posting forms had not been accurately completed.
Failure to perform hand hygiene during resident feeding. During dining room observations, an employee assisted with one resident's wheelchair and then fed a resident without sanitizing her hands or changing gloves. In interview, the employee acknowledged she did not properly sanitize her hands before returning to feed the resident, and the Corporate Kitchen Manager stated he was aware of the lack of hand sanitization in the dining room.
A resident with leg immobilizers developed unstageable pressure ulcers due to the facility's failure to implement a care plan for skin integrity checks. The resident reported that the braces were not removed for a week, leading to hospitalization and debridement. The facility also misidentified a blister on another resident and failed to provide consistent wound care for a third resident.
A resident, who had not used his manual wheelchair for over a year due to paralysis, was transported in a facility van after being denied the use of his power wheelchair. Despite staff concerns about his safety, the resident insisted on using the manual wheelchair and subsequently slid from it during transport, resulting in fractures. The facility failed to follow its policy of evaluating residents after a fall before moving them, leading to an Immediate Jeopardy situation.
The facility failed to develop comprehensive care plans for several residents, leading to unmet needs. A resident's food dislikes were not documented, resulting in inappropriate meal service. Another resident's skin condition lacked interventions in their care plan. A resident with PTSD had no support documented, and their use of leg immobilizers was not addressed. Additionally, a resident's risk for pressure ulcers due to a knee immobilizer was not documented, and a blister was not properly assessed or reported. These deficiencies were confirmed by the DON and staff.
A pharmacist failed to accurately complete monthly Medication Regimen Reviews for three residents, including one who was NPO but still receiving oral medications. The Director of Nursing could not locate documentation of the pharmacist's recommendations for two residents, contributing to the deficiency.
A nurse involved in an accident was unable to perform her duties, leading to a missed medication handoff. The replacement nurse did not administer medications due to unclear communication, resulting in several residents missing significant medications. The facility identified the error the next morning, and no adverse reactions were reported.
The facility did not follow the menu for a noontime meal, affecting 10 residents. The Certified Dietary Manager (CDM) ran out of broccoli, which was part of the planned meal, due to over-scooping portions. Consequently, residents were served only pinto beans, pan-fried potatoes, and cornbread, missing the required broccoli.
The facility failed to maintain accurate and complete medical records for 18 residents, leading to issues such as undocumented brace removal, conflicting code status and PTSD diagnosis, missed medication doses due to an internet outage, incorrect transfer dates, and conflicting NPO orders. Additionally, a resident's catheter care plan lacked a corresponding medical diagnosis. These deficiencies highlight significant lapses in record-keeping and documentation practices.
The facility failed to maintain resident dignity by including undignified pictures in the medical records of two residents with Stage II pressure ulcers. The pictures showed brown substances in the residents' briefs, which the DON confirmed as undignified. This was discovered during a survey process.
A resident, dependent on staff for ADL care due to recent illness, was observed unable to reach her call light, which had been moved by a nurse aide. Her reaching tool was also out of reach. The Director of Marketing and Admissions acknowledged the issue and returned the call light and reacher to the resident.
A facility failed to notify a resident's physician when the resident developed a blister on the lower leg. The medical record contained an order for wound care, but there was no documentation of physician notification. This deficiency was confirmed by the DON during an interview.
A facility failed to provide adequate information for a safe transition of care when a resident was transferred to the hospital. The transfer form did not document existing pressure ulcers on the resident, which was confirmed by the DON. This deficiency was identified during a review of the resident's medical record and staff interviews.
The facility failed to provide a bed hold policy for a resident who was transferred twice to an acute care facility due to altered mental status and increased urinary incontinence. Record reviews and interviews with the Business Office Manager confirmed the absence of a bed hold policy for both transfers, which was acknowledged by the DON.
A facility failed to accurately document a resident's pressure ulcers in the MDS, incorrectly marking them as present on admission when two were acquired in-house. This was confirmed by skin evaluations and an interview with the Clinical Reimbursement Coordinator.
The facility failed to document mental health diagnoses accurately in the PASARR for two residents. One resident's TBI diagnosis was omitted, and another resident's PAS lacked several diagnoses, including personality disorder and PTSD. The omissions were confirmed by facility staff.
A facility failed to update a resident's care plan to reflect their current code status. A review showed a discrepancy between the resident's POST form, which indicated DNR, and the care plan, which incorrectly stated FULL CODE. This inconsistency was confirmed by an LSW during an interview.
A facility failed to provide trauma-informed care to a resident with PTSD, as their care plan lacked documentation of PTSD, military service, and personal losses. The resident independently arranged VA counseling, with no records in the facility's files until requested by surveyors. Interviews revealed the facility did not assess triggers or have a treatment plan in place.
A facility failed to maintain an effective infection control program when oxygen nasal tubing was observed on the floor beside a resident's bed for three consecutive days. Despite multiple observations, the tubing remained in the same position until a staff member confirmed it should not be on the floor and disposed of it.
Failure to Honor Full Code POST Orders During Resident’s Decline and Unresponsiveness
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s Physician Orders for Scope of Treatment (POST) and advance directives requiring full code and full interventions. The resident had a POST form completed in accordance with state requirements, signed by the resident, specifying CPR with resuscitation efforts including mechanical ventilation, defibrillation, and cardioversion, and full medical and surgical interventions with the goal of sustaining life by all medically effective means. The resident’s MDS admission assessment documented a BIMS score of 15, indicating intact cognition, and a physician determination of capacity confirmed that the resident demonstrated capacity to make decisions. The resident’s care plan reflected activation of the resident’s advanced directive as full code, including full treatments and tube feeding as indicated, with a goal that the resident’s wishes as expressed in the advance directive would be followed. Progress notes show that the resident experienced a decline in condition over time, including decreased participation in therapy, increased weakness, poor oral intake, fatigue, low blood pressure, refusal of medications, and a coccyx wound with odor. On one date, staff expressed concern to the PA that the resident remained full code despite this decline. The PA documented that the resident, who had decision-making capacity, was counseled about prognosis and offered hospice and comfort measures; the resident declined and explicitly chose to remain full code with heroic efforts to sustain life. Subsequent documentation noted that medications were held due to the resident’s decline in condition. On a later date, a progress note documented that the resident remained on a steady decline, was unresponsive to sternal rub and other physical stimuli, had an irregular increased pulse of 124, and was having difficulty breathing. The physician attempted to contact the resident’s son multiple times to change the POST to DNR status but was unable to reach him, and staff continued to monitor and document changes rather than initiate full code interventions in accordance with the existing POST. A subsequent progress note indicated that the family later notified staff that the resident was unresponsive, at which point an LPN started chest compressions and an AED was applied, and EMS assumed care and administered emergency medications before time of death was called. In interview, the DON and ADON acknowledged they were aware the POST specified full code and full interventions, stated they called the son for direction because they believed the resident could not make decisions on the date of death, and admitted that the resident’s directive was not followed.
Unsanitary Conditions in Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in resident rooms and bathrooms on the 100 hall, including rooms 101, 102, 103, and 104. During an entrance walkthrough, surveyors observed brownish smears behind a toilet handrail, a dark red smeared substance on a toilet handrail, a sticky yellowish substance on a wall behind a resident's bed, dusty residue on the base of an empty hand sanitizer dispenser, smeared brownish substance on a bathroom wall behind toilet handrails and under a soap dispenser, blackish substance around a toilet base, cobwebs, built-up hair and dusty residue under a sink, and black substance build-up around baseboards and a toilet base. A second walkthrough the next day found the issues had not been resolved. A Corporate RN acknowledged the conditions during a walk-through, and the Administrator later acknowledged the issues in the resident rooms and bathrooms.
Improper Food Storage and Hand Hygiene During Tray Line Prep
Penalty
Summary
Food was not properly stored in accordance with professional standards of practice. During an initial kitchen tour, surveyors observed opened boxes of frozen sausage links, frozen biscuit dough, and frozen pizza dough left unclosed and exposed to air in the freezer. They also observed utensils in the utensil drawer scattered in different directions rather than placed uniformly, and a bottle of onion spice on a shelf above the stove left open to air. During tray line preparation, Employee #72 was observed touching the inside of a plate with bare hands and touching cabinet doors without washing hands or changing gloves. Employee #76 was observed leaving tray line prep to move a full tray cart into the hall and then returning to the tray line without washing hands or changing gloves. In interviews, both employees acknowledged the hand hygiene lapses, and the Kitchen Manager and corporate Kitchen Manager acknowledged the open food containers and the observations of absent hand sanitation on the tray line.
Bed Mattress Overhang Created an Unsafe Sleeping Surface
Penalty
Summary
The facility failed to ensure the resident environment under its control was as free from accident hazards as possible in regard to bed safety for Resident #28. During an initial tour on 01/18/26 at 12:26 PM, Resident #28 was observed lying on a bariatric mattress placed on a standard bed frame, with approximately 12 inches of the mattress hanging over the frame and leaving an unsupported area. During an interview later that day at 12:45 PM, the DON verified that the mattress was hanging over the frame and stated that it should not be larger than the frame. On 01/21/2026 at 10:35 AM, the Maintenance Assistant stated that he replaced the bariatric mattress because it was too big for the frame.
Incomplete Daily Nursing Staff Posting
Penalty
Summary
The facility failed to ensure the daily nursing staff form posted was accurate and complete. During observation, the daily nursing staff form was incomplete for January 17, 2026, January 18, 2026, and January 19, 2026, because the daily census was not included on the posting for those days. The facility census was 52. During interview, the DON concurred that the nurse staff posting forms had not been accurately completed.
Failure to Perform Hand Hygiene During Resident Feeding
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, based on unsanitary practices observed in the dining room. During dining room observations on 01/19/26 at approximately 12:15 PM, Employee #23 was observed assisting with one resident's wheelchair and then assisting in feeding Resident #10 without properly sanitizing her hands and without changing her gloves. In a later interview on 01/19/26 at 12:45 PM, Employee #23 acknowledged that she did not properly sanitize her hands before returning to feed Resident #10. During an interview on 01/20/26 at approximately 11:15 AM, the Corporate Kitchen Manager stated he was aware of the lack of hand sanitization in the dining room on 01/19/26.
Failure to Prevent Pressure Ulcers in Residents with Leg Immobilizers
Penalty
Summary
The facility failed to prevent the development of avoidable pressure ulcers in a resident who returned from the emergency room with bilateral leg immobilizers. The resident, who was cognitively intact and had a history of paraplegia, reported that the braces were not removed for a week after returning to the facility, during which time the staff failed to check the skin integrity. This oversight led to the development of bilateral unstageable pressure ulcers on both calves, which worsened and required hospitalization and debridement procedures. The medical record review revealed that the facility did not have a care plan in place for the removal of the braces to check for skin integrity, despite the resident's condition and the presence of leg immobilizers. The treatment administration record indicated that skin observations were supposedly conducted, but the resident denied that these checks occurred. The facility's failure to implement a proper care plan and conduct regular skin assessments contributed to the deterioration of the resident's condition. Additionally, the facility misidentified a blister on another resident's leg as an edema blister instead of a pressure ulcer and failed to perform regular wound evaluations. Another resident did not receive wound care consistent with current standards of practice. These deficiencies were observed in three out of four residents reviewed for pressure ulcer care during the survey process, indicating a broader issue with the facility's wound care practices.
Resident Safety Compromised During Transport
Penalty
Summary
The facility failed to ensure a safe environment for a resident, leading to an accident during transportation. A resident, who had not used his manual wheelchair for over a year due to paralysis in both lower extremities, requested to be transported to the bank in the facility van. The facility had previously decided not to allow power wheelchairs in the van, but the resident insisted on using his manual wheelchair despite staff concerns about his safety. During the transport, the resident slid from the wheelchair, resulting in bilateral tibia and fibula fractures. The facility's policy required that a resident not be moved after a fall until evaluated by a physician, nurse, or emergency medical services. However, after the resident slid from the wheelchair, two nurse aides lifted him back into the wheelchair without such an evaluation. The resident, who was a paraplegic and could not feel his legs, denied pain and did not want to go to the hospital. The facility's failure to follow its policy and ensure the resident's safety in the manual wheelchair contributed to the incident being classified as an Immediate Jeopardy situation. Interviews with staff revealed that the resident was insistent on going to the bank and did not want to wait for a safer transportation arrangement. The Director of Rehab expressed concerns about the resident's trunk control and safety in the manual wheelchair, but the resident's demands were prioritized. The facility's decision to restrict power wheelchair use in the van without notifying affected residents and ensuring alternative safe transportation options contributed to the accident.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in addressing their specific needs. Resident #23 expressed a strong dislike for chicken and turkey, which was not documented in their care plan, resulting in meals being served that did not align with their preferences. This oversight was confirmed by the Director of Nursing (DON) upon review. Resident #14's care plan identified a focus area of impaired skin due to factors such as obesity and moisture, but it lacked any interventions to address these issues. The absence of interventions was acknowledged by the DON, indicating a gap in the care plan's comprehensiveness. Similarly, Resident #8, who had a history of PTSD, did not have this condition or its triggers addressed in their care plan. The resident reported receiving no facility-provided support for PTSD, relying instead on self-arranged counseling through the VA. Additionally, the care plan failed to address the use of leg immobilizers and the necessary skin integrity checks, a deficiency confirmed by the DON. Resident #4's care plan also lacked focus, goals, or interventions related to maintaining skin integrity while using a knee immobilizer. Although the resident reported a blister caused by a previous brace, this was not documented in the care plan, nor was there evidence of physician notification. The DON and RN confirmed the absence of a SWIFT assessment for the blister, highlighting a failure to document and address the resident's risk for pressure ulcers. These deficiencies were confirmed through interviews and record reviews, underscoring the facility's failure to provide comprehensive and individualized care plans for its residents.
Pharmacist's Incomplete Medication Regimen Review
Penalty
Summary
The pharmacist failed to accurately review and complete the monthly Medication Regimen Review (MRR) for three out of five residents assessed for unnecessary medication during the Long Term Care Survey process. For one resident, who was ordered to be Nothing by Mouth (NPO), the pharmacist did not identify that the resident was still receiving multiple oral medications, including Acetaminophen, Milk of Magnesia, Midodrine, and Sennosides, which were not appropriate given the NPO status. This oversight was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the MRR completed after admission did not address the NPO orders. For another resident, the pharmacist completed a drug regimen review and made recommendations, but the Director of Nursing was unable to locate the documentation of these recommendations. Similarly, for a third resident, the pharmacy review indicated that comments and recommendations were made, but the DON could not find the specific recommendations for that month. This lack of documentation and follow-up on the pharmacist's recommendations contributed to the deficiency identified during the survey.
Medication Administration Failure Due to Inadequate Handoff
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as discovered during a complaint survey. On a particular evening, a nurse who was involved in an automobile accident reported to work but was unable to perform her duties effectively. She was sent home, and another nurse arrived to cover her shift approximately an hour later. However, due to unclear communication and lack of a proper handoff, it was uncertain whether the medications had been administered, leading to the omission of nighttime medications for several residents. The Director of Nursing (DON) confirmed that the nurse involved in the accident left around 9:00 PM, and the replacement nurse arrived between 10:00 PM and 10:30 PM. The replacement nurse did not administer the medications because they were not initialed off on the Medication Administration Record and were showing red on the electronic medical record system. The DON was unsure if the medications had been given and did not want to risk double dosing, resulting in the medications not being administered. The residents affected by this error missed significant medications, including anticoagulants, insulin, and medications for hypertension, seizures, and nerve pain. The facility identified the errors the following morning, and the physician assessed each resident, finding no adverse reactions. However, the incident highlighted a failure in the facility's process for ensuring medication administration during unexpected nurse absences.
Menu Not Followed During Meal Service
Penalty
Summary
The facility failed to ensure that menus were followed for the noontime meal on 11/18/24, affecting 10 residents who were dining in the facility's dining room. During the meal service, it was observed that the Certified Dietary Manager (CDM) ran out of broccoli, which was supposed to be part of the meal according to the menu. As a result, the residents were only served pinto beans, pan-fried potatoes, and cornbread, without the required half cup of broccoli. An interview with the CDM revealed that she over-scooped the broccoli portions, leading to the shortage. This oversight resulted in 10 residents not receiving the complete meal as planned.
Inaccurate and Incomplete Medical Records
Penalty
Summary
The facility failed to ensure the completeness and accuracy of medical records for 18 residents during a long-term care survey. For Resident #4, there was no documentation indicating that the resident's brace was removed and the skin was checked for integrity, despite the resident stating that staff removed the brace daily. The Director of Nursing (DON) provided an updated order but could not show prior documentation of the brace removal. Resident #8's medical record contained conflicting information regarding code status and a diagnosis of PTSD, with the social service assessment inaccurately reflecting the resident's wishes and medical history. On 07/08/24, multiple residents' medication administration records were incomplete due to an internet outage, and the facility lacked a backup paper system to document medication administration. This resulted in significant medication errors for several residents, including missed doses of critical medications such as Eliquis, Insulin, and Rivaroxaban. Additionally, Resident #23's transfer form contained an incorrect transfer date, and Resident #47 had conflicting orders regarding NPO status and oral medications, which were attributed to prepopulated standing orders not being properly reviewed. Resident #209 had an order and care plan for a catheter due to urinary retention, but the medical diagnosis for urinary retention was missing from the medical record. The DON confirmed the absence of this diagnosis. These deficiencies highlight the facility's failure to maintain accurate and complete medical records, which is essential for ensuring proper resident care and treatment.
Undignified Pictures in Medical Records
Penalty
Summary
The facility failed to treat residents with dignity by including undignified pictures in their medical records. During a record review, it was discovered that two residents, identified as Resident #40 and Resident #43, had pictures in their medical records that were deemed undignified. Resident #40 had a Stage II pressure ulcer on her sacrum upon admission, and the medical record contained two pictures of the ulcer. One picture showed a brown lumpy substance in the resident's brief, and another showed a brown substance smeared up the intergluteal cleft. During an interview, the wound nurse stated that wounds are cleaned before pictures are taken, but the Director of Nursing confirmed that the pictures were undignified. Similarly, Resident #43, who also had a Stage II pressure ulcer, had two pictures in her medical record showing a brown substance in her brief. The wound nurse reiterated the procedure of cleaning wounds before taking pictures, but upon review, the Director of Nursing acknowledged the undignified nature of the images. These findings were made during a random opportunity for discovery in the Long-Term Care Survey Process, with the facility census at 54.
Resident's Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which was identified during a random observation. The resident, who requires assistance for activities of daily living due to recent illness and hospitalization, was observed struggling to reach her call light during an interview. She mentioned that the nurse aide had moved the call light while making her bed, leaving it out of reach. Additionally, her reaching tool was also placed on the other side of the room. When the surveyor rang the call light, it was answered by the Director of Marketing and Admissions, who acknowledged the issue and returned the call light and reacher to the resident.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the attending physician of a change in condition for a resident who developed a blister on the lower leg. The resident's medical record included an order to cleanse and dress the blister, dated 10/31/24, but there was no documentation indicating that the physician was informed of this development. This deficiency was confirmed during an interview with the Director of Nursing, who acknowledged the absence of evidence in the medical record regarding physician notification. This oversight was identified during a review of care for pressure ulcers, affecting one of the three residents reviewed in this area.
Inadequate Transfer Documentation for Hospitalized Resident
Penalty
Summary
The facility failed to ensure the receiving hospital received adequate information for a safe and effective transition of care for Resident #8. The resident was transferred to the hospital, and the transfer form used by the facility did not document existing pressure ulcers on the resident's sacrum, left and right calf, and right thigh. This omission was confirmed by the Director of Nursing during the survey process. The deficiency was identified during a review of the resident's medical record and staff interviews, highlighting a lapse in communication regarding the resident's condition at the time of transfer.
Failure to Provide Bed Hold Policy for Resident Transfers
Penalty
Summary
The facility failed to provide a bed hold policy to a resident for two separate transfers to an acute care facility. The resident was transferred on two occasions, once for altered mental status and once for altered mental status and increased urinary incontinence. During a record review, it was found that the facility did not have a bed hold policy in place for either transfer. Interviews with the Business Office Manager confirmed the absence of a bed hold policy for both instances. The Director of Nursing was notified and confirmed that the bed hold policy should have been completed for these transfers.
Inaccurate MDS Documentation for Pressure Ulcers
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) for a resident accurately reflected the status of pressure ulcers as either in-house acquired or present on admission. This deficiency was identified during a long-term care survey process, where it was found that the MDS for a resident with three unstageable pressure ulcers inaccurately documented all ulcers as present on admission. However, skin evaluations revealed that two of the pressure ulcers on the resident's calves were actually acquired in-house. This discrepancy was confirmed through an interview with the Clinical Reimbursement Coordinator.
Failure to Accurately Document Mental Health Diagnoses in PASARR
Penalty
Summary
The facility failed to accurately identify and document certain mental health diagnoses on the Pre-Admission Screening and Resident Review (PASARR) for two residents during the Long-Term Care Survey Process. For one resident, the record review revealed a diagnosis of Traumatic Brain Injury (TBI) as an admitting diagnosis, which was not included in the PASARR dated April 28, 2022. During an interview, the Licensed Social Worker confirmed the omission of the TBI diagnosis from the PASARR, attributing the oversight to the absence of the staff member responsible for completing the PASARR. For another resident, the medical record review showed multiple diagnoses, including personality disorder, bipolar disorder, post-traumatic stress disorder (PTSD), insomnia, and mood disorder due to a known physiological condition with depressive features. However, the most recent Pre-Admission Screening dated December 2, 2023, only included the bipolar disorder diagnosis, which was noted to be well-controlled with medication. The PAS did not trigger a level II evaluation, and the Social Service Director confirmed that the PAS needed updating to reflect all current diagnoses.
Failure to Update Care Plan for Code Status
Penalty
Summary
The facility failed to revise a care plan related to a resident's code status, which was identified during the Long-Term Care Survey Process. Specifically, a review of records for a resident revealed a discrepancy between the POST form and the care plan. The POST form, dated 10/31/24, indicated that the resident was marked as Do Not Attempt Resuscitation (DNR). However, the care plan for the same resident incorrectly stated that the resident had an advanced directive of FULL CODE on file. This inconsistency was confirmed during an interview with the Licensed Social Worker, who acknowledged that the care plan had not been updated to reflect the resident's current code status.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care to a resident identified as a trauma survivor with PTSD. During the survey, it was discovered that the resident's care plan did not include any mention of PTSD, his military service, or the traumatic loss of his son and friends. The resident reported that he had not received any specific services from the facility to assist with his PTSD and had independently arranged counseling through the Veteran Administration (VA). The facility did not have any records of this counseling in the resident's medical record until requested by the surveyor. Interviews with the Director of Nursing (DON) and the Social Service Director revealed that the facility relied on the resident to inform them of any recommendations from his VA counselor. The DON confirmed that there were no VA records in the resident's file prior to the surveyor's request. The Social Service Director acknowledged that the resident's triggers had not been assessed, and there was no treatment plan in place to address his PTSD. This lack of documentation and proactive care planning led to the deficiency identified during the survey.
Infection Control Deficiency: Oxygen Tubing on Floor
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the improper handling of oxygen nasal tubing for a resident. Observations on three consecutive days revealed that the oxygen nasal tubing was left on the floor beside the resident's bed and under a chair. Despite being observed on the floor on 11/18/24, the tubing remained in the same position during subsequent observations on 11/19/24 and 11/20/24. A staff member confirmed that the tubing should not have been on the floor and disposed of it after the third observation.
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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 Morgantown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sundale Nursing Home | 1.6 mi | ★★★★★ | 0 | 0 |
| Morgantown Healthcare Center | 1.7 mi | ★★★★★ | 1 | 0 |
| Morgantown Heights Of Journey | 2 mi | ★★★★★ | 16 | 0 |
| Uniontown Nursing And Rehab | 17.2 mi | ★★★★★ | 1 | 0 |
| Majestic Care Of Manchin | 17.5 mi | ★★★★★ | 0 | 0 |
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