Madeira Healthcare Center

In the surveyor’s words

From the most serious findings on record at Madeira Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 4, 2024

  Based on observation, medical record review, staff interviews, review of a police report, and review of the facility policy, the facility failed to provide adequate supervision and implement timely interventions for exit-seeking behaviors for Resident #37, who was cognitively impaired, had a history of wandering and exit seeking behavior and who resided in a secured unit, to prevent his elopement from the facility without staff knowledge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death on [DATE] when Resident #37 left the secured unit, got in a car in the parking lot which had the keys inside and drove approximately 8.2 miles away from the facility. […]

• Actual harm, isolatedF686Aug 11, 2022

  Based on record review, observation, resident interview, staff interview, review of facility policy, and review of the National Pressure Ulcer Advisory Panel (NPUAP) guidance, the facility failed to adequately assess and monitor a resident's skin resulting in actual harm when Resident #05 developed a Deep Tissue Injury (DTI) pressure ulcer to her foot from a splint. Additionally, the facility failed to implement wound treatments for Resident #05 based on the Wound Nurse Practitioner's (WNP) #430 recommendations, leading to the ulcer deteriorating. Lastly, the facility failed to adequately assess and monitor Resident #90's skin resulting in actual harm when Resident #90 developed an unstageable pressure ulcer to his heel. […]

• No harm, potential for more than minimal, widespreadF812Apr 4, 2022

  Based on observation, staff interview, and policy review, the facility failed to ensure food was prepared, stored, and served in a manner to prevent the spread of foodborne illness. This had the potential to affect 74 out of 75 residents. The facility identified one resident (#50) who received nothing by mouth and did not receive food from the kitchen. The facility census was 75. Findings include: 1. Observation on 03/28/22 at 9:52 A.M. of the walk-in refrigerator revealed a tray containing seven small plastic containers with covers. The containers contained yellow jello with marshmallows and had 3/12 on the lid. […]

• No harm, potential for more than minimal, widespreadF814Apr 4, 2022

  Based on observation and staff interview, the facility failed to ensure trash cans in the food preparation area were covered. This had the potential to affect all 74 residents who receive meals from the kitchen. The facility identified one resident (#50) who received nothing by mouth and did not receive food from the kitchen. The facility census was 75. Findings include: Observation on 03/28/22 at 8:18 A.M. revealed an uncovered trash can on wheels next to the counter, which contained the meat slicer. Observation on 03/28/22 at 11:45 A.M. […]

• No harm, potential for more than minimal, widespreadF880Mar 2, 2022

  Based on observation, staff interview, policy review, and review of the Centers for Disease Control (CDC) website, the facility failed to ensure staff wore personal protective equipment (PPE) in a manner to prevent the potential spread of Coronavirus Disease 2019 (COVID-19). This had the potential to affect all 75 residents in the facility. The census was 75. Findings included: 1. Observation and interview with Housekeeping (HKSP) #139 on 02/23/22 at 8:40 A.M. revealed she had on a KN95 mask that had ear loop straps which went behind the ears. HKSP #139 was observed going in and out of resident rooms. HKSP #139 stated she ordered the KN95 masks and was not wearing the masks the facility provided. […]