A list of the most recent deficiencies for Madison Grove Post Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-12 | 2023-01-31 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-12 | 2023-01-31 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-01-12 | 2023-01-31 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-12 | 2023-01-31 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-10 | 2022-10-26 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-10-10 | 2022-10-26 | Y |
| Provide emergency officials' contact information. | Fire Safety | 2022-04-26 | 2022-05-24 | N |
| Use approved construction type or materials. | Fire Safety | 2022-04-26 | 2022-05-24 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-04-26 | 2022-05-24 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-04-26 | 2022-05-24 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-04-26 | 2022-05-24 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-04-26 | 2022-05-24 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-26 | 2022-05-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-26 | 2022-05-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-04-26 | 2022-05-24 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-04-26 | 2022-05-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-26 | 2022-05-24 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-04-25 | 2022-05-19 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2022-04-25 | 2022-05-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-25 | 2022-05-19 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-25 | 2022-05-19 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-04-25 | 2022-05-19 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-04-25 | 2022-05-19 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-04-25 | 2022-05-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-25 | 2022-05-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-25 | 2022-05-19 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-10-19 | 2021-11-30 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-10-19 | 2021-11-30 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-10-19 | 2021-11-30 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2021-10-19 | 2021-11-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-10-19 | 2021-11-30 | N |
| Provide activities to meet all resident's needs. | Health | 2021-10-19 | 2021-11-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-19 | 2021-11-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-19 | 2021-11-30 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-10-19 | 2021-11-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-19 | 2021-11-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-10-19 | 2021-11-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-19 | 2021-11-30 | N |
| Dispose of garbage and refuse properly. | Health | 2021-10-19 | 2021-11-30 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-10-19 | 2021-11-30 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-10-19 | 2021-11-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-10-19 | 2021-11-30 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-10-19 | 2021-11-30 | N |
| Use approved construction type or materials. | Fire Safety | 2021-10-18 | 2021-11-02 | N |
| Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. | Fire Safety | 2021-10-18 | 2021-11-02 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2021-10-18 | 2021-11-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-10-18 | 2021-11-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-18 | 2021-11-02 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-10-09 | 2021-10-18 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-10-09 | 2021-10-18 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-08 | 2021-10-18 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-10-01 | 2021-10-18 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-30 | 2021-10-18 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-23 | 2021-10-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-22 | 2021-10-05 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-06-14 | 2021-08-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-06-14 | 2021-08-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-14 | 2021-08-17 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-14 | 2021-08-17 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-07-22 | 2021-08-12 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-12 | 2021-05-27 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2021-05-04 | 2021-05-27 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-05-04 | 2021-05-27 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-05-04 | 2021-05-27 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-05-04 | 2021-05-27 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-05-04 | 2021-05-27 | N |
| Use approved construction type or materials. | Fire Safety | 2021-05-04 | 2021-05-27 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2021-05-04 | 2021-05-27 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-05-04 | 2021-05-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-05-04 | 2021-05-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-05-04 | 2021-05-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-04 | 2021-05-27 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-05-04 | 2021-05-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-05-04 | 2021-05-27 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-05-04 | 2021-05-27 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-26 | 2021-05-21 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-26 | 2021-05-21 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-26 | 2021-05-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-26 | 2021-05-21 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-04-26 | 2021-05-21 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-04-26 | 2021-05-21 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-04-26 | 2021-05-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-26 | 2021-05-21 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-04-26 | 2021-05-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-04-26 | 2021-05-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-26 | 2021-05-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-26 | 2021-05-21 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-04-26 | 2021-05-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-20 | 2021-05-06 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-04-11 | 2021-04-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-14 | 2021-04-26 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-04-12 | 2021-04-26 | Y |
