Madison Post Acute

In the surveyor’s words

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

• Immediate jeopardy, widespreadF607Aug 18, 2022

  Based on interview, and record review the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse and/or neglect for four of four residents (21, 28, 254, and 255) reviewed for abuse and neglect. These failures resulted in one resident's grievance of rough handling, one resident's grievance of verbal abuse, and two residents that had injuries of an unknown origin to not be identified, protected, investigated, or reported as potential allegations of abuse and/or neglect by the facility. These failures left all residents at risk for abuse and/or neglect and psychosocial harm. […]

• Immediate jeopardy, widespreadF880Aug 18, 2022

  Based on observation, interview, and record review the facility failed to ensure the staff were compliant with Infection Prevention and Control Guidelines and standards of practice for three of three halls. The facility failed to ensure the staff appropriately cleaned and disinfected glucometers (point of care device used to assess the level of sugar in blood) per the device and manufacturer's instructions. The facility failed to ensure oversight and implementation of their Infection Prevention and Control Program and management of the Coronavirus Disease 2019 (an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness], headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell,… […]

• Actual harm, isolatedF600Oct 16, 2023

  Based on interview and record review, the facility failed to ensure 1 of 2 sampled residents (Resident 11) was free from physical and mental abuse from staff. The facility failed ensure resident protection, and implement interventions to prevent mental and physical abuse when Staff AA, Nursing Assistant Certified (NAC), was allowed to continue to care for vulnerable residents. Resident 11 experienced harm when the facility did not intervene, safeguard, or protect the resident after they alleged on [NAME] than one occasion unwanted physical touching, laughing at the resident's requests, and emotional distress from Staff AA. These failures placed all residents at risk for abuse. […]

• Actual harm, isolatedF686Aug 18, 2022

  Based on observation, interview, and record review, the facility failed to ensure necessary care and services were provided to prevent pressure ulcer development for 4 of 5 residents (41,13,17 and 36) reviewed for facility acquired pressure ulcers. This failure caused harm to Resident 41, who developed a preventable unstageable (eschar/dead tissue) left heel ulcer and an un-blanchable reddened left great toe ulcer, causing the resident pain and impacting the resident's rehabilitation and discharge potential. The facility additionally failed to prevent the development of new stage 2 pressure injury for Resident 36 and failed to implement effective preventitive skin measures for residents 13 and 17. These failures placed residents at risk for adverse outcomes and decreased quality of life. […]

• Actual harm, isolatedF742Aug 18, 2022

  Based on observation, interview and record review, the facility failed to ensure a resident with a history of trauma was provided appropriate treatment and services for one of two residents (4) reviewed for mental health treatments. The failure to monitor and evaluate the resident's status and underlying causes for changes in mood/behavior, offer resources and services to help cope with their depression, and create an individualized treatment plan; resulted in psychosocial harm, unmet emotional needs, and a diminished quality of life. Findings included . RESIDENT 4 Resident 4 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Annual Minimum Data Set (MDS) assessment dated [DATE] showed the resident had intact cognition. […]