Madisonville Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Nov 7, 2025

  Based on observation, interview, and record review the facility failed to provide the care and supervision to prevent accidents for 1 of 7 (Resident #1) residents reviewed for accidents and hazards. The facility failed to ensure that Resident #1, who had a history of wandering and was high risk for elopement on admission, was prevented from exiting the facility without staff supervision on 10/22/2025 and found wandering outside the facility alone approximately 20 minutes later by staff. The facility was not aware that she was not in the building when she was found. The noncompliance was identified as Past Noncompliance (PNC). The IJ template was provided to the facility on [DATE] at 5:05PM. The IJ began on 10/22/2025 and ended 10/23/2025. […]

• Immediate jeopardy, isolatedF686Oct 8, 2021

  Based on observation, interview, and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and once developed, failed to ensure necessary treatment and services to promote healing and prevent new ulcers from developing for three of six residents reviewed for pressure ulcers. (Resident #52, #46, and #2) A) The facility failed to ensure Resident #52 who was admitted to the facility without pressure ulcers and was low risk for the development of pressure ulcers did not developed a Stage II pressure ulcer that progressed to a Stage IV pressure ulcer in 26 days. […]

• Actual harm, patternF550Mar 3, 2026

  Based on observations, interviews and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 4 residents (R#1). 1. The facility failed to ensure R#1's preferences for showers were adhered to as he was receiving a bed bath, which made him feel dirty, down, depressed, and like a prisoner. 2. The facility failed to ensure R#1 was assessed timely for safety awareness in his electric wheelchair after his last reassessment on 12/27/25. These failures could place residents at risk of psychosocial harm. […]

• Actual harm, isolatedF686Jan 30, 2022

  Based on observation, interview and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and once developed, failed to ensure necessary treatment and services to promote healing for one (Resident #3) of three residents reviewed for pressure ulcers. The facility failed to ensure Resident # 3 who had no pressure ulcers and was at risk for the development of pressure ulcers did not develop a Stage II pressure ulcer that progressed to an unstageable pressure ulcer in 14 days. […]

• Actual harm, isolatedF689Jun 4, 2021

  Based on observation, record review and interviews, it was determined the facility failed to ensure the facility remained free of accidents as possible for one of eight residents (Resident #1) and have proper operation of one of four exit doors with alarms. A. The facility failed to ensure Resident #1's care plan was followed during a transfer from her bed to her wheelchair. Resident #1's care plan reflected she was a two person assist with transfers and CNA C transferred her without assistance. The resident sustained a spiral fracture to her left femur (thigh bone) during the transfer. B. A door leading to the outside from the dining room was left unmonitored and the alarm deactivated. […]