Madison House

The overhead light in the activity office storeroom is missing the cover and exposing the electrical wiring.

There was an extension cord utilized as permanent wiring in room 202.

The portable electric heater in the activity office is plugged into a power strip.

There are two 2 inch gaps in the grease filters in the kitchen.

Six resident room fire doors were blocked open preventing them from closing and latching.

The fire rated cross corridor door near room 226 would not close and latch from the fully open position.

Missing inspection and flow test documentation; mixed sprinkler head types found in multiple rooms.

Overhead light in activity office storeroom is missing cover, exposing wiring.

Extension cord used as permanent wiring in room 202.

Portable electric heater in activity office is plugged into a power strip.

Two 2-inch gaps in kitchen grease filters.

Resident room fire doors 437, 445, 459, 351, 324, and 307 were blocked open, preventing latching.

Fire rated cross corridor door near room 226 does not close and latch from fully open position.

Missing documentation for annual sprinkler inspection and NFPA 25 forward flow test; mixed sprinkler head types found in club room, dining room, and President room.

Failed to document the quarterly reevaluation in writing for electronic surveillance for Resident 5.

Failed to ensure Apartment 10 was approved by the department for occupancy.

Staff A and Staff D did not have documentation of completed national fingerprint background checks.

Facility failed to ensure 5 of 9 residents' medical devices (bed canes/side rails) were safe and free of entrapment hazards due to wide gaps between vertical bars.

Two laundry rooms used by residents/staff lacked required mechanical ventilation to the outside.

Staff A, D, and F lacked documentation for required basic training, specialty training, continuing education, or Home Care Aide certification.

One resident lacked the required Medicaid policy acknowledgement documentation on a separate form.

Failed to complete full assessments for Residents 3, 4, and 6, missing clinical needs, medications, or diagnosis documentation.

Staff A (Administrator) lacked documentation of basic training requirements and Home Care Aide certification.

Service plans for Residents 3, 4, and 6 failed to include interventions for specific clinical needs or monitoring instructions.

Staff A did not complete the 70-hour basic training requirement and lacked HCA certification for the administrator position.

Kitchen secured cable is not attached to Cooking Appliances on Casters.

Broken/bent receptacle covers in dining room and 2nd floor med room.

Blocked electrical panels found in kitchen.

No established schedule for inspection of Fire-Rated construction provided.

Penetrations found around pipe outside of room 300.

Stairwell doors by room 451 and 351 will not latch.

Painted sprinkler head by room 351 and missing escutcheon outside room 351.

Laundry chutes need to be tested.

No schedule for annual fire door inspections provided.

Facility failed to assess 3 of 3 sampled residents for their ability to use medical devices (bedrails/transfer poles) and failed to perform required risk assessments for these devices.

2 of 14 sampled kitchen staff and caregivers (Staff E and Staff F) failed to maintain a current food handlers' card.

Facility failed to complete written medication assistance plans for 4 of 4 sampled residents and failed to keep significant medications on-site for Resident 2.

Facility failed to screen 5 of 5 sampled staff for TB upon hire; failed to screen 1 of 1 sampled staff (Staff D) for TB; failed to follow required procedures for staff with positive TB test results.

Facility failed to ensure 1 of 1 sampled resident (Resident 1) received medications in a safe manner; Medication Technician improperly measured topical medication.

Facility failed to maintain continuing education training records for 2 of 2 sampled staff (Staff E and Staff U) to verify required hours.

Facility failed to obtain written consent for nurse delegation for Resident 8 and failed to implement required nurse delegation services for medication administration for Resident 1.

The licensee failed to ensure one staff member was tested for tuberculosis. This was an uncorrected deficiency previously cited on February 14, 2024.

The licensee failed to test one staff member for tuberculosis as required. This was an uncorrected deficiency previously cited on February 14, 2024.

Missing schedule for inspection of Fire-Rated construction and annual inspection of fire-resistance-rated construction.

Observed issues in closet by resident room 215 and 3rd floor theater room.

Quarterly inspection paperwork not provided.

Need to determine fuse link size and perform heat survey for kitchen hood.

2nd floor fire extinguisher needs to be relocated inside room.

Fire extinguisher in copy room found on counter rather than on hanger.

Fire alarm circuit breaker in electrical room is missing required lock device.

Missing schedule for fire door inspections; observed large gaps in doors 230 and 235.