The Madison on Marsh

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Apr 17, 2025

  Based on interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 (Resident #2) of 4 residents reviewed for elopement. The facility failed to provide adequate supervision to Resident #2 and as a result, the resident eloped from the facility and was found by a passerby between 12:00 pm and 2:00 pm in front of a local store (8.9 miles) away from the facility. Resident # 2 was gone from the facility for over five and a half hours and last seen on 02/22/25 at 1:41 AM. Resident #2 was taken to a hospital on [DATE] at 2:00 PM, and a nurse from the hospital notified the facility. […]

• No harm, potential for more than minimal, widespreadF814May 27, 2021

  Based on observation, interview and record review it was determined the facility failed to dispose garbage and refuse properly for the dumpster area for 1 of 1 dumpster reviewed for proper storage of garbage and refuse, in that; The facility failed to keep the only dumpster area clean and the dumpster lids/doors closed. This failure could affect the residents by placing them at risk for infection and a decreased quality of life due to an exterior environment which could attract flying pests, rodents and other animals. Findings included: On 05/27/21 at 9:10 a.m. observed the dumpster with the left side sliding door open, there was debris on the ground outside of the door. The items son the ground was a syringe without needle, an IV tubing, several used gloves and tissues. […]

• No harm, potential for more than minimal, patternF553Feb 26, 2026

  Based on interview and record review the facility failed to ensure the residents had the right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to the right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care for 4 of 6 residents (Residents #2, #20, #27 and #73) reviewed for Resident Rights.The facility failed to ensure Residents #2, #20, #27 and #73, and/or the resident's representative were invited and given the opportunity to participate in the resident's care plan meetings.This failure could place residents at risk of a decline in… […]

• No harm, potential for more than minimal, patternF850Feb 26, 2026

  Based on interview and record reviews the facility failed to ensure a facility with more than 120 beds employed a qualified social worker on a full-time basis for 1 of 1 (facility) reviewed for social worker qualifications.The facility, licensed for 125 beds, failed to employ a full-time social worker.This failure could place residents at risk of social service and psychosocial needs not being met.Findings include:In a record review of the facility's daily census, dated 02/26/2026, revealed the facility had a total licensed bed capacity of 125. […]

• No harm, potential for more than minimal, patternF812Apr 17, 2025

  Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. The facility failed to ensure food items in the facility walk-in refrigerator were covered, labeled, and dated. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination. Findings included: Observation on 04/16/25 at 11:40 AM of the facility's walk-in refrigerator revealed: 1. A plastic container had food that looked like sausage was not labeled. 2. A plastic container had some kind of red sauce was not labeled or dated. 3. […]