Madisonville Health and Rehabilitation, LLC

Based on observation, interview, and review of facility policy, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This failure had the potential to affect all residents who consumed meals from the kitchen.Observation of the kitchen, on 05/20/2026, revealed multiple food items uncovered in the freezer and dry storage pantry; and a box of uncovered oatmeal cookie dough in the freezer stored underneath an ice-covered condenser. Additionally, there were several large bins which contained salt, sugar, and breadcrumbs, which were soiled on the outside.Further, observation on 05/21/2026, revealed the [NAME] was not wearing a beard net properly, in order to cover all facial hair. Additionally, observation revealed the box of uncovered oatmeal cookie dough was again in the freezer stored underneath the ice-covered condenser, and had not been discarded.The findings include:Review of the facility policy titled, Food Storage-Dry Goods, dated 10/2019, revealed the facility's policy would ensure all dry goods were…

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, interview and review of facility policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.During observation of the laundry room on 05/22/2026, the two staff members present were asked to verbalize the process on handling soiled linen. They both stated they only wore gloves when handling soiled linen instead of the standard precaution of donning gloves and a gown. This failure had the potential to affect all residents in the facility.Additionally, the facility failed to ensure proper infection control procedures during wound care treatment for one of three sampled residents reviewed for wound care, Resident (R)67. During observation of wound care on 05/20/2026, Licensed Practical Nurse (LPN)2 set up a sterile field while wearing clean gloves and placed a plastic bag in the floor for soiled wound care materials. She then failed to perform hand hygiene and don new…

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, interview, record review, and review of facility policy, the facility failed to provide food that accommodated resident preferences for 1 of 26 residents in the dining room during meal service on 05/20/2026, Resident (R) 69. Observation of lunch meal service on 05/20/2026, revealed R69 was given ice cream as a substitute item for dessert, without asking if he wanted the scheduled strawberry shortcake dessert.The findings include: Review of the facility policy, titled Resident Rights, reviewed 04/2026, revealed the resident has the right to and the facility must have promoted and facilitated resident self-determination through the support of resident choice. The resident has the right to make choices about aspects of his life in the facility. Review of R69's Face Sheet located in the Electronic Medical Record (EMR), revealed the facility admitted the resident on 01/25/2024 with diagnoses including history of a stroke, hypertension, and non-Alzheimer's dementia. Review of R69's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of…

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, interview, and review of the facility's policy, the facility failed to ensure residents had a right to a safe, clean, sanitary, and comfortable environment. Observations in the facility's laundry room on 04/17/2026 revealed the floor around and behind the washing machines covered in dirt and the concrete floor in disrepair.The findings include:Review of the facility's policy titled Safe and Homelike Environment, revised 06/01/2025, revealed it was the facility's policy to ensure that the resident can receive care and services safely and that the physical layout of the facility does not pose a safety risk. Further review of the policy revealed it was the facility's policy to provide a sanitary environment by keeping resident care equipment clean and properly stored, including equipment used in the completion of the activities of daily living.Review of the facility's policy titled Resident Rights, revised 06/2025, revealed the resident has the right to a safe, clean, comfortable, and homelike environment.Review of the Facesheet revealed the facility admitted…

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, interview, record review, and review of facility policy, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice regarding wound care for 1 of 2 residents sampled for skin assessments out of the total 18 sampled residents, (Resident (R)21). The findings include: Review of the facility policy, Wound Treatment Management, revised on 03/24/2025, revealed the facility's policy was to promote wound healing of various types. Per review, it was the policy of the facility to provide evidence-based treatments in accordance with current standards of practice and physician's orders. Review of R21's facesheet revealed the facility admitted the resident on 10/18/2013, with diagnoses which included, anoxic brain damage, epilepsy, and hemiplegia and hemiparesis following cerebral infarction. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the facility had not completed the Brief Interview for Mental Status…

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, interview, record review and facility policy review, the facility failed to establish and maintain an infection prevention and control program to ensure a sanitary, safe environment or 2 of 18 sampled residents, (Resident (R)62 and R21. The findings included: Review of the facility policy, Hand Hygiene, revised 03/19/2024, revealed all staff were to perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. Per review, that applied to all staff working in all locations within the facility. Continued review revealed staff were to perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Further review revealed the use of gloves would not replace hand hygiene. In addition, review revealed staff were to perform hand hygiene prior to donning gloves, and immediately after removing gloves. 1. Review of the facesheet for R62 revealed the facility admitted the resident on 07/20/2022, with…

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, interview, and review of facility policy, the facility failed to ensure the corridors were equipped with hand rails on each side as required. The findings include: Review of the facility policy titled, Resident Rights, revised 03/22/2022, revealed the resident had the right to a safe, clean, comfortable, home-like environment, including but not limited to treatments and supports for daily living safety. Review of the facility policy titled, Accidents and Supervision, revised 02/21/2024, revealed the residents' environment was to remain as free of accident hazards as possible. The policy further stated each resident was to receive adequate assistive devices to prevent accidents. Observation on 04/29/2025 at 2:40 PM, revealed the corridor outside of the dayroom had a hand rail secured to only one side with a bookshelf located on the other side. In interview on 05/01/25 at 3:10 PM, the Facility Maintenance Director stated the bookshelf was already located on that wall before he became Maintenance Director in March of this year. He stated he was not aware of 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, interview, and review of the facility maintenance policy it was determined the facility failed to provide a safe, comfortable, and homelike environment for residents. Observation on 01/14/2020 revealed two (2) of four (4) facility hallways (Round Station and C Hall) had baseboard heaters with missing and/or bent cover panels. In addition, one (1) of eight (8) rooms in the Round Station hallway (room [ROOM NUMBER]) had a broken heating and air-conditioning electrical outlet cover. The findings include: A review of the maintenance policy titled Work Orders and Maintenance Services, undated, revealed maintenance work orders shall be completed in order to establish a priority of maintenance services and the maintenance director was responsible for scheduling preventive maintenance services. Observations conducted on the Round Station hall on 01/14/2020 at 12:20 PM revealed four (4) of six (6) baseboard heaters with bent, loose, and/or missing cover panels. Observation on the C Wing hall 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 observation, interview, and review of the facility policy, it was determined the facility failed to ensure infection control practices were maintained in the kitchen. On 01/14/2020, at 12:03 PM, during service of the lunch meal, observation revealed a contract repairman working on the dishwasher was not wearing a hair net. The findings include: Review of the facility policy, Personal Hygiene, undated, revealed the key to a safe and sanitary Dietary Department was healthy employees, properly trained in safe food handling, and the practice of good hygiene. The policy also revealed if hair was long and not covered properly by a cap, a hair net must be worn. Observation in the kitchen on 01/14/2020 at 12:03 PM, revealed an individual working on the dishwasher who was not wearing a hair net. Further observation revealed the kitchen staff were plating and serving the lunch meal for the residents. At 12:15 PM, observation revealed the repairman donned a hair net after he stated to the surveyor that he thought he needed a hair net. Interview with the Dietary Manager on 01/16/2020…

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 and interview, the facility failed to ensure controlled drugs were stored in a permanently affixed compartment as required in one (1) of two (2) refrigerators in the medication rooms. Observation of the B Hall medication room revealed the locked narcotic box in the refrigerator was not permanently affixed to the refrigerator. The findings include: Review of the facility policy titled Controlled Substances, with a revision date of December 2019 and a reviewed/revised date of 08/14/2019, revealed that controlled substances must be stored in the medication room in a locked container, separate from containers for any non-controlled medications. The policy did not address that the locked box would be permanently affixed. Observation of the B Hall medication room on 01/16/2020 at 2:45 PM revealed a locked plastic container in the refrigerator that was being utilized for storage of narcotic medications; however, the container was not permanently affixed to the refrigerator and could be easily removed from the refrigerator. Observation of the contents of the narcotic…

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.