Madigan Estates

In the surveyor’s words

From the most serious findings on record at Madigan Estates, in the surveyor’s own words.

• Actual harm, isolatedF689Nov 14, 2023

  Based on facility reported incident review, facility investigation, record review, and interviews, the facility failed to ensure that a resident received the proper level of assistance during a transfer when a Certified Nursing Assistant (CNA) did not review how the resident transferred and used a single assist bear hug method, when the resident was a two person Hoyer Mechanical Lift for 1 of 1 incidents received (10/26/23). The failure to transfer the resident via Hoyer Lift resulted in Resident #2 [R2] requiring transfer to an acute care hospital, sustaining a non-displaced fracture proximal to the right tibia, experiencing pain and anxiety after the injury occurred. […]

• No harm, potential for more than minimal, patternF684Jul 30, 2026

  Based on clinical record reviews and interviews, the facility failed to follow physician orders or enter treatment orders for wounds when found for 5 of 20 residents reviewed (Resident #9 [R9], R62, R63, R39, and R98). Findings: 1. On 7/28/26, R9's clinical record was reviewed and included an order to administer Humalog Mix insulin with breakfast and supper but to hold it if blood sugar was less than 100. A review of R9's blood sugars and Treatment Administration Record [TAR] indicated that on 7/23/26 at 7:54 a.m., R9's blood sugar was 88 but the TAR indicated the insulin was still administered. On 7/29/26 at 1:55 p.m., during an interview with the Director of Nursing [DON], a surveyor confirmed this finding. 2. […]

• No harm, potential for more than minimal, patternF684Mar 21, 2024

  Based on interviews, record review, and observation, the facility failed to ensure that a physician order for a mechanical soft diet was followed for 1 of 3 residents reviewed for nutrition (Resident #5 [R5]). Findings: On 3/18/24 at 10:34 a.m., in an interview with the surveyor, R5 stated, The food is good most of the time, but I have a hard time chewing it. On 3/19/24 at 8:24 a.m., review of R5's clinical record indicated the physician's diet order initiated on 4/26/23 was mechanical soft diet texture for trouble chewing, poor dentition. The care plan was updated on 4/27/23 to include a diet of Regular Diet, Mechanical Soft. […]

• No harm, potential for more than minimal, patternF695Mar 21, 2024

  Based on observations and interviews the facility failed to ensure respiratory care equipment was hooked up properly for 1 of 1 resident reviewed for respiratory care (Resident #143 [R143]) Finding: R143 was admitted on [DATE] with diagnosis of hypoxic and hypercapnic respiratory failure secondary to cor pulmonale, sleep apnea and Chronic Obstructive Pulmonary Disease On 3/18/24 at 1:41 p.m. during resident interview and observation. The surveyor observed R143 was on oxygen at 2 liters/minute via nasal canula (NC), there was a humidification bottle that was not attached to the NC tubing. R143 NC was hooked up directly to the oxygen concentrator at 2 liters/minute. The clear tubing on top of the humidification bottle was sticking straight up in the air. On 3/19/24 at 7:30 a.m. […]

• No harm, potential for more than minimal, patternF761Mar 21, 2024

  Based on observations and interviews, the facility failed to ensure expired medications and topicals were removed from the supply available for use in 2 of 2 treatment carts (#1 and #2), 1 of 1 medication carts (#2) and 2 of 2 medication storage rooms (#1 and #2) reviewed. In addition, the facility failed monitor temperatures in a medication refrigerator that insulin was stored in for 1 of 2 medication storage rooms (#1). Findings: 1. Treatment Cart #1 On 3/20/24 at 1:20 p.m., a surveyor and Registered Nurse (RN)2 observed a tube of Medihoney Gel (used for wounds) with an expiration date of 2/1/24, a tube of Hydrophilic wound dressing with an expiration date of 1/24, and a tube of Aquaphor healing ointment with an expiration date of 11/22. 2. […]