Madison Health Care

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jun 17, 2024

  Based on closed medical record review, review of an emergency medical transportation record, review of facility policy, and interviews, the facility failed to provide goods and services to Resident #105 to prevent an incident of neglect resulting in the resident ' s death. This resulted in Immediate Jeopardy and actual harm/death beginning on [DATE] at approximately 8:18 P.M. when Resident #105, who had advance directives for a full code status was noted to exhibit behaviors and then subsequently requested (at around 12:00 A.M. on [DATE]) the use of an as needed bronchodilator (Albuterol) inhalation medication (used to treat or prevent bronchospasm and increase air flow to lungs) without further assessment or monitoring. On [DATE] at 12:37 A.M. […]

• No harm, potential for more than minimal, widespreadF801Jun 25, 2026

  Based on interviews and record review, the facility failed to maintain a qualified dietary manager. This had the potential to affect all 99 residents residing in the facility.Findings include:Interview with Dietary Director (DD) #601 on 06/24/26 at 9:27 A.M. revealed he was not a certified dietary manager or certified food service manager. He had no other certification specific to management of a food service program, no associates or higher degree in food service or hospitality, and no prior experience as a dietary director in a nursing facility. […]

• No harm, potential for more than minimal, widespreadF814Mar 13, 2025

  Based on observation and staff interview, the facility failed to maintain its dumpster area in a clean and sanitary manner. This had the potential to affect all 102 residents residing in the facility. Findings include: Observation of the facilities dumpster area on 03/10/25 at 8:35 A.M. revealed two dumpster lids were not closed on one of two dumpsters. The top lid was open, and the side door was open with cardboard boxes hanging out the side. Interview at the time of the observation with Dietary Manager #381 verified the condition of the dumpsters at the time of observation.

• No harm, potential for more than minimal, widespreadF921Mar 13, 2025

  Based on observation, interview, review of housekeeping staffing schedules, documentation of room cleanings and facility policy review, the facility did not ensure the environment was maintained in a safe, sanitary and comfortable manner affecting 31 Residents (#1, #2, #3, #5, #7, #8, #11, #17, #18, #20, #21, #22, #23, #24, #27, #34, #37, #38, #40, #46, #56, #58, #60, #64, #66, #67, #71, #73, #81, #92, and #156) out of 102 residents observed for environment. Also, the facility had a dark unlit parking lot that had the potential to affect all 102 residents residing in the facility. Findings include: 1. Observations on the initial tour on 03/10/25 from 9:05 A.M. to 10:04 A.M. […]

• No harm, potential for more than minimal, widespreadF804Nov 1, 2023

  Based on observation, interview, and review of facility policy the facility failed to ensure food was palatable related to temperature and taste. This had the potential to affect all 103 residents residing in the facility. Findings include: Observation on 10/26/23 at 7:32 A.M. of the tray line for the breakfast meal revealed a sausage patty, homemade french toast, fortified cream of wheat, pureed french toast, pureed sausage, orange juice, other types of juice and milk were on the menu for breakfast. Further observation revealed a tray on a cart next to the tray line area with many bowls of oatmeal with plastic lids on it. Cook #402 stated she put the oatmeal in dishes and placed them on the tray before tray line was started. Observation on 10/26/23 at 7:32 A.M. […]