Madison Health And Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, and review of the facility's policy titled, Medication Storage in the Facility, the facility failed to dispose of expired medical supplies in one of one medication storage rooms. This deficient practice had the potential to place residents at risk for infection and ineffective treatment. The facility census was 66 residents. Findings include: A review of the facility's policy titled Medication Storage in the Facility, effective date of [DATE], under Policy revealed, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendation. those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications. Under the section titled Procedures revealed, (L.) Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's policy titled Resident's Rights Policy and Procedure, the facility failed to ensure that the right to respect, dignity and privacy was maintained by displaying clinical information related to incontinence care and pressure ulcer care that was posted openly in the room for one out of 26 sampled residents (R) R63. Findings include: Review of the undated facility policy titled, Resident's Rights Policy and Procedure, for the section titled Purpose revealed, The facility protects and promotes the rights of each resident admitted in order to provide a dignified existence, self-determination, and communication with an access to persons and services inside and outside the facility. The facility will protect and promote the rights of each resident. Under section titled Policy, subsection titled Privacy and Confidentiality revealed under number one, You have a right to respect and privacy in your medical, personal, and bodily care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure the resident environment was free from accident hazards for one out of 26 sampled residents (R) (R19). Specifically, the facility failed to replace an assistance device to prevent accidents as evidence by the bed control was defective with exposed wires present. Findings include: Review of admission Record revealed R19 was admitted with diagnoses that included but not limited to, cerebrovascular disease affecting right dominant side, muscle weakness, unsteadiness on feet, abnormal posture, and other pulmonary embolism without acute cor pulmonale. Review of R19's quarterly Minimum Data Set (MDS) dated [DATE] for Section C (Cognitive Patterns) revealed, a Brief Interview for Mental Status score of five which indicated severe cognitive impairment; Section GG (Functional Abilities and Goals) revealed, the resident had impairment on one side to upper and lower extremity and was dependent on staff with mobility. Observation and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and review of the facility's policies titled, Food Storage, Dietary Safety Rules, Dishwashing, and Cooking pots and Steam Table Insert Storage Policy & Procedure, the facility failed to label, and date opened food items in the freezers, walk-in refrigerator, and dry storage area; failed to ensure male staff cover facial hair while in the kitchen; and failed to store pans properly to prevent wet nesting and cross contamination. This affected 61 of 62 residents receiving an oral diet. Findings include: 1. Review of the facility's policy titled, Food Storage revealed all items must be covered, labeled, and dated. All foods that have been opened and partially used shall be dated and sealed before returning to a storage area. Observation on 3/24/2023 at 8:20 a.m. of the reach in freezer near the milk refrigerator revealed a one gallon container of vanilla ice cream that had been opened with no open date. Observation on 3/24/2023 at 8:25 a.m. of the reach in freezer near the fryer revealed a plastic resealable bag with two frozen waffles with no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and review of facility policy titled, Abuse Prohibition, Policy and Procedure, the facility failed to complete a background check screening process for two of 10 nursing staff reviewed. Findings include: Review of the facility policy titled, Abuse Prohibition, Policy and Procedure revised [DATE] revealed it is the intent of this facility to actively preserve each resident's right to be free from mistreatment, neglect, abuse, or misappropriation of resident property. Procedures: 1. Screening and Hiring Practices: B. Prior to hiring an employment applicant, the nursing home shall request a criminal record check from GCIC (Georgia Crime Information Center) for Licensed Staff and have applicant submit to a GCHEX (Georgia Criminal History Check System) fingerprint background check for all other staff to determine whether the applicant is Satisfactory for Employment. Review of the facility employee files revealed the following: 1. Licensed Practical Nurse (LPN) EE was hired on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, staff interview, and review of the facility's policy titled, Automatic Stop Orders, the facility failed to ensure a stop date was implemented, not to exceed 14 days for antipsychotic medications, for one of six residents (R) (R#10) reviewed for unnecessary medications. Specifically, the facility failed to implement a stop date for antipsychotic medication ordered as needed (PRN) for R#10, increasing the potential for adverse consequences. Findings include: A review of the facility's policy, Medication Orders-Stop Orders, effective date 11/28/2017, revealed PRN orders for psychotropic drugs are limited to 14 days. A further review revealed PRN antipsychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. A review of the medical record revealed the resident was admitted to the facility with a past medical history of dementia without behaviors, malnutrition, edema, hypothyroidism, hyperlipidemia, dehydration, acidosis, bipolar, major…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and staff interviews, the facility failed to ensure dietary staff followed recipes for preparing pureed foods to avoid compromising the nutritive value, flavor, or appearance. This affected seven of 61 residents receiving an oral diet. Findings include: Review of the recipe for puree chicken revealed for 10 servings to process until smooth 10 - two ounce portions chicken, two tablespoons plus one and one half teaspoons food thickener, and one and one fourth cup chicken broth. Review of the recipe for sweet potatoes (yams) was to place canned yams in mixing bowl, mash, and whip on high speed until smooth. For pureed diets top whipped sweet potatoes with one tablespoon of butter. Review of the recipe for Italian green beans for 10 servings revealed to process until smooth 10 and one half cups prepared green beans. Add three tablespoons plus one teaspoon of food thickener. Observation on 3/25/2023 at 11:30 a.m. of dietary cook DD preparing puree chicken strips, yams and green beans revealed no recipes were seen or used as reference during…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interviews, record review, and review of the facility's policy titled, Facility COVID-19 Vaccination Plan, the facility failed to ensure 100 percent (%) of all current staff that were providing care for facility residents were fully vaccinated against COVID-19. Findings include: Review of the facility's policy titled, Facility COVID-19 Vaccination Plan, revealed . All staff members will be given information on vaccination from the CDC [Centers for Disease Control and Prevention] about the SAR-CoV-2 [COVID-19] vaccine that is available to our facility through the local health department and/or the facility's pharmacy provider. Vaccination will be encouraged but not required. Should a staff member decline vaccination, medical or religious exemption will be required to continue working in the facility. Review of the facility's Covid-19 data for fully/partially vaccinated staff submitted to the National Health and Safety Network (NHSN) as of 3/25/2023 documented the staff vaccination rate at 100.0%. However, the 100.0 rate was including the 3 partially vaccinated staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record review the facility failed to employ a qualified Dietary Manager. This had the potential to affect 60 of 60 residents residing in the facility. Findings include: Review of dietary certifications in the kitchen did not reveal evidence of a 'Certified' or qualified Dietary Manager. An interview on 6/7/2021 at 10:05 a.m. with the Dietary Manager (DM) revealed she took over the position of DM approximately one year ago but has been working at the facility since November 2016. She indicated she does not have a DM Certification and is not currently enrolled in a Certified Dietary Manager course at this time. An interview on 6/10/2021 at 10:32 a.m. with Administrator revealed the DM has been with them for several years. He reported the DM started as a dining room attendant and kitchen aide. When the previous DM left, they promoted her March 2019, to DM because she showed the most drive. The Administrator confirmed that he is aware of the regulatory requirements for a qualified dietary manager and further confirmed the DM does not have a certification. He…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and review of policies titled Food Storage, Food Production, and General Food Preparation and Handling, the facility failed to properly label food items, failed to properly thaw meat, failed to maintain clean equipment, and failed to keep staff drinks separate from facility foods. This had the potential to affect 60 of 60 residents residing in the facility. Findings include: Review of facility policy titled Food Storage dated 2013 revealed . 4. All containers must be legible and accurately labeled and dated. 8. All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods. a. old stock is always used first (first in - first out method), c. Food should be dated as it is placed on the shelves. d. Date marking to indicate the date or day by which a ready to eat, potentially hazardous food should be consumed, sold, or discarded will be visible on all high risk food (see chart on next page). e. Foods will be stored and handled to maintain the integrity of the packaging until…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview the facility failed to ensure that privacy curtains provided full visual privacy, which included a total of 11 of 12 rooms on one hall. Findings include: During the initial tour on 6/7/2021 between 10:45 a.m. and 12:00 p.m. observation revealed resident privacy curtains with a width space/gap which did not ensure full visual privacy coverage during patient/resident care, including rooms 100, 123, 125, 127, 129, 131, 132, 133, 134, 135, and 136. An observation and interview was conducted on 6/10/2021 at 10:35 a.m. with Certified Nursing Assistant (CNA) BB in room [ROOM NUMBER] revealed that the CNA stated the curtains are not the correct size to go around the resident to provide privacy during care. An interview and observation was conducted on 6/10/2021 at 10: 30 a.m. with the Maintenance Assistant (MA) and Environmental Supervisor (EVS) revealed that both became aware of the privacy curtain width for approximately two weeks. The EVS revealed that every room in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews and the review of the policy titled, Maintenance Department Policy and Procedure the facility failed to provide a safe/clean/comfortable/ homelike environment on one out of two halls (front hall) and two out of two shower rooms. The facility census was 60. Findings include: Review of the policy titled, Maintenance Department Policy and Procedure dated 3/18/2020 indicated; To Assure proper maintenance of the physical plant. General Facility Maintenance: The department will do ongoing monitoring of the facility for areas needing repair. Miscellaneous: Leaks and areas of moisture should be fixed promptly and drywall, ceiling tiles and other materials should be replaced. An observation on 6/8/2021 at 9:33 a.m. room [ROOM NUMBER] of the bathroom shared by two residents, and the area around the toilet was orange-brown rust color and the toilet paper holder was rusted. An observation on 6/8/2021 at 9:39 a.m. of the water fountain located between room [ROOM NUMBER] and 123 covered…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.