Madison, The

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Jan 21, 2026

  Based on record review and staff interview, the facility failed to ensure Resident #65's Physician Orders for Scope of Treatment (POST) form was honored by directions specified by the [NAME] Virginia Center for End-of-Life Care in conjunction with the [NAME] Virginia Health Care Decisions Act (16-30-1).This has to potential to affect all residents that reside in the facility. Resident identifiers: 65.The facility was notified of the Immediate Jeopardy (IJ) at 4:35 PM on [DATE]. The facility submitted their first abatement plan of correction (POC) at[DATE] at 5:29 PM. The state agency requested changes and the second abatement POC was submitted [DATE] at 6:01PM. The abatement POC was accepted by the state agency at 6:05 PM on [DATE]. […]

• Immediate jeopardy, isolatedF686Nov 21, 2024

  Based on resident interview, record review, staff interview and observation, the facility failed to ensure a resident did not develop avoidable pressure ulcers. Resident #8 returned from the emergency room with bilateral leg immobilizes. The facility failed to implement a plan to prevent Resident #8 from developing pressure ulcers because of the leg immobilizers. Resident #8 developed bilateral unstageable pressure ulcers to both calves. The wounds have worsened and required the resident to be hospitalized and undergo debridement procedures on each of the wounds. The resident has voiced concerns and fears that his right leg will need an amputation because of the wound. […]

• Immediate jeopardy, isolatedF689Nov 21, 2024

  Based on record review, resident interview and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. Resident #8 requested the facility transport him to the bank in the facility van. The facility had decided prior to Resident #8's request to go to the bank that power wheelchairs could not be used on the facility van any longer. As a result of this decision the resident requested his manual wheelchair and chose to use the manual wheelchair in the van to go to the bank. The resident had not been in his manual wheelchair for at least a year prior to this. Since then, he had lost use of his legs and was paralyzed in both lower extremities. The resident slid from the wheelchair while on the van. […]

• Immediate jeopardy, isolatedF600Dec 9, 2021

  Based on record review, staff interview and observation, the facility failed to provide services to a resident that are necessary to avoid death, physical harm, pain, mental anguish or emotional distress by not following the Resident's original signed West Virginia Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice affected Resident #54, who is now deceased . This deficient practice had the potential to also affect one of the fifty-one (51) residents at the facility with POST forms. Resident identifiers: #54. Facility census 51 The facility was notified of the IJ (Immediate Jeopardy) at 1:12 PM on [DATE]. The facility submitted their abatement plan of correction (POC) at 2:13 PM on [DATE] and was forwarded to the State Office for review. […]

• Actual harm, isolatedF684Dec 9, 2021

  Based on observation, record review, resident and resident representative interview, and staff interview, the facility failed to identify and provide needed care and services that are resident centered and in accordance with the residents' plans of care and orders. The facility failed to promptly identify and intervene for an acute change in Resident #13's condition. This harmed Resident #13 by causing increased pain and by affecting the resident's ability to be independent in bed mobility, ambulating, eating, and toileting. The facility also failed to perform neurological assessments when Resident #13 had an unwitnessed fall. Additionally, the facility failed to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]