Madrid Home for the Aged

In the surveyor’s words

From the most serious findings on record at Madrid Home for the Aged, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF605Mar 26, 2026

  Based on clinical record review staff interview, and policy review the facility failed to identify non-pharmacological interventions and targeted behaviors related to high risk medications in 4 out of 5 sampled residents reviewed (Resident #2, #29, #1, and #4). The facility reported a census of 54 residents.Findings include:1. Review of Resident #2's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognitive functioning. The MDS indicated that Resident #2 was taking antidepressant medications during the look back period. […]

• No harm, potential for more than minimal, patternF812Mar 26, 2026

  Based on observations, interviews, and facility policy review, the facility failed to prepare, serve and distribute food in accordance with food service safety. The facility also failed to ensure sanitary and safe conditions in the two kitchenette areas in the facility maintained for food services. These failures posed the risk of food borne illness to the residents. The facility reported a census of 54 residents. Findings include:Observation on 3/25/26 in the facility's kitchen of the noon meal service with Staff B, Dietary Aide/Cook revealed at:11:36 a.m., he put on a pair of disposable gloves and took a plate with those gloves on he touched a pair of tongs to plate one piece of beef steak with mushroom and onion gravy from the steam table, a scoop to plate the mashed potatoes, a ladle… […]

• No harm, potential for more than minimal, patternF812Mar 20, 2025

  Based on observations, record review, staff interview, and policy review, the facility failed to ensure and verify food was stored, prepared, and delivered in a manner to prevent foodborne illness. The facility reported a census of 52. Findings include: During a continuous observation of the kitchen on 3/17/25 at 9:00 AM, the following was identified: a. Undated dish machine test strips stuck to the first aid kit hanging on a wall; Out of the 31 test strips, 14 strips indicated the high-temperature dish machine did not reach the required rinse temperature of >/= 180 b. Plastic jug of a chemical marked erosive was stored with food in the dry storage area c. No temperature logs maintained for the walk-in cooler, walk-in freezer, or the reach-in coolers d. […]

• No harm, potential for more than minimal, patternF760Mar 27, 2023

  Based on observations, staff interviews, and facility policy review the facility failed to prevent significant medication errors to 4 of 4 residents reviewed (Resident #5, Resident #18, Resident #32 and Resident #37). The facility reported a census of 41 residents. Findings include 1. Resident #32's Minimum Data Set (MDS) dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 3, indicating severe cognitive impairment. The MDS included diagnoses of anemia (low blood iron), deep vein thrombosis (DVT, blood clot), and hypertension (high blood pressure). The MDS listed an admitted [DATE]. […]

• No harm, potential for more than minimal, patternF812Mar 27, 2023

  Based on observation, staff interview, and policy review the facility failed to store and prepare food in accordance with professional standards for 41 of 41 residents. The facility reported a census of 41 residents. Findings include On 3/20/23 from 10:30 AM through 11:30 AM during a continuous observation of the initial kitchen tour revealed: a. The reach-in refrigerator contained four pounds (lbs) of whipped margarine and fruit jello without an open date. b. The walk-in freezer lacked an open date on a plastic container of parmesan cheese, a bag of chicken patties, a bag of breaded chicken, a 48 ounce (oz) container of strawberry ice cream, and on a bag of chicken strips. c. […]