Madison Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Madison Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF835Mar 4, 2022

  Based on interview, record review, and review of the facility's Administrator's and Director of Nursing's Job Descriptions, it was determined the facility failed to be administered in a manner that enabled effective use of its resources to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to maintain substantial compliance, after the 05/21/2020, Abbreviated Survey, in the areas of 42 CFR 483.10 Notification of Change (F580); 42 CFR 483.25 Quality of Care (F684); 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F657); and 42 CFR 483.70 Resident Records-Identifiable Information (F842). […]

• Immediate jeopardy, widespreadF837Mar 4, 2022

  Based on interview, record review, and review of the facility's policy, it was determined the facility's Governing Body failed to ensure facility policies were implemented regarding management and operation of the facility. The Governing Body failed to ensure compliance in the areas of 42 CFR 483.10 Resident Rights,F580; 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F657; 42 CFR 483.25 Quality of Care, F684 and F697; and 42 CFR 483.70 Administration, F842 during the 05/21/2020 Abbreviated Survey. Continued non-compliance was cited during this Survey at 42 CFR 483.10 Resident Rights, F580; 42 CFR 483.21 Comprehensive Resident Centered Care Plan, F657; 42 CFR 483.25 Quality of Care, F684 and F697; and 42 CFR 483.70 Administration, F842. […]

• Immediate jeopardy, widespreadF867Mar 4, 2022

  Based on observation, interview, record review, review of facility policy, and review of the facility's Plan of Correction submitted for 05/21/2020 survey, it was determined the facility failed to have effective processes in place to address system failures through regularly scheduled Quality Assurance Performance Improvement (QAPI) meetings. As a result, the facility failed to identify quality of care deficiencies, failed to develop and implement plans of action to correct identified quality of care deficiencies, and failed to ensure standards for quality of care regarding performance improvement measures were achieved and sustained. […]

• Immediate jeopardy, widespreadF880Mar 4, 2022

  Based on observation, interview, record review, and review of the facility's policies, it was determined 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 and control the development and transmission of communicable diseases, including COVID-19. The facility further failed to implement recommended interventions as per the Centers for Medicare and Medicaid Services (CMS), the Center for Disease Control and Prevention (CDC), and the Kentucky Department for Public Health (Health Department) State guidelines for COVID-19, which affected all residents. […]

• Immediate jeopardy, isolatedF580Mar 4, 2022

  Based on interview, record review, and review of the facility's policy, it was determined the facility failed to notify the physician for one (1) of thirty-three (33) sampled residents (Resident #428) when the resident experienced a change of condition and there was a need to alter treatment. Resident #428 had experienced a decrease in food and fluid intake since [DATE], which continued after the resident was diagnosed with COVID-19 on [DATE] and moved to the facility's COVID unit. However, there was no evidence the resident's physician was notified of the resident's decrease in food/fluid intake. […]