Madison Healthcare Services

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Feb 28, 2024

  Based on observation, interview, and document review, the facility failed to ensure the resident safety from accident and hazards for 1 of 1 resident (R149) who smoked unsupervised while using oxygen via nasal cannula that was connected to a compressed oxygen (O2) canister. This resulted in an immediate risk of serious harm, injury, or death, from thermal burns to R149. In addition, the facility failed to follow facility policy and secure smoking materials (cigarettes and lighter) away from R149. The IJ began on 2/19/24 when R149 was admitted to the facility (a non-smoking facility) and with facility knowledge, smoked unsupervised while wearing oxygen upon her admission. […]

• Immediate jeopardy, isolatedF689Apr 14, 2022

  Based on observation, interview and document review, the facility failed to provide appropriate supervision and comprehensively assess exit seeking behaviors for 1 of 1 resident (R1). This resulted in an immediate jeopardy (IJ) when R1 was able to repeatedly exit the East door to the facility on to an unsafe walkway with stairs to one side and a sloped sidewalk to the other. The IJ began on 3/25/22, when R1 exited the building and was observed outside by a visitor. Staff were notified and R1 was returned to the building. R1 was not comprehensively re-assessed at that time to determine causative factors, needed interventions, or was provided appropriate supervision when exhibiting those behaviors to prevent R1 from further attempts to exit the building to return home. […]

• Immediate jeopardy, isolatedF689Oct 7, 2021

  Based on observation, interview and document review, the facility failed to develop elopement prevention interventions upon R1's admission even though R1 was at moderate risk for elopement, and staff were aware R1's had exit seeking attempts before R1 successfully eloped from the facility. The immediate jeopardy (IJ) began on 9/23/21 at 1:03 p.m., when it was determined the facility failed to provide elopement prevention interventions and R1 eloped. The chief executive officer and interim director of nursing (DON) was informed of the IJ on 10/6/21, at 6:29 p.m. The IJ was removed on 10/7/21, at 2:38 p.m. however, non-compliance remained at an isolated scope and severity which indicated no actual harm with potential for more than minimal harm (Level D). […]

• Actual harm, isolatedF689Dec 17, 2021

  Based on observation, interview and document review, the facility failed to properly implement fall prevention interventions to prevent reoccurring falls for 2 of 3 residents (R5, R3) reviewed for accidents. This deficient practice resulted in actual harm for R5, who sustained thoracic spine comprehension fractures. Findings include: R5's Face Sheet dated 7/11/19, indicated R5 was admitted to the facility on [DATE], with initial diagnoses of weakness and repeated falls. R5's Diagnosis Report updated 12/13/21, added the diagnosis of wedge compression fracture of thoracic vertebra. […]

• No harm, potential for more than minimal, widespreadF880Aug 12, 2021

  Based on observation, interview, and document review, the facility failed to ensure appropriate signage was posted and appropriate personal protective equipment (PPE) worn by all staff on 1 of 1 (quarantined for potential COVID) designated unit housing 20 of 39 residents (R1, R2, R4, R5, R6, R7, R9, R10, R14, R17, R18, R19, R20, R21, R22, R23, R24, R30, R32, and R37). The facility also failed to appropriately document 3 of 3 residents (R1, R5, and R10) identified symptoms of potential COVID-19. This had the potential to affect all 39 residents. […]