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Deficiency Records for Complete Care at Madison, LLC
A list of the most recent deficiencies for Complete Care at Madison, LLC. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Complete Care at Madison, LLC. 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? |
|---|---|---|---|---|
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-08-27 | 2024-09-20 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-08-27 | 2024-09-19 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-08-27 | 2024-09-19 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-08-27 | 2024-09-19 | 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 | 2024-08-27 | 2024-09-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-08-27 | 2024-09-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-27 | 2024-09-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-08-27 | 2024-09-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-08-27 | 2024-09-19 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-08-27 | 2024-09-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-08-27 | 2024-09-19 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-08-27 | 2024-09-19 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2024-08-27 | 2024-09-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-08-27 | 2024-09-18 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-08-27 | 2024-09-16 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-08-27 | 2024-09-09 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-08-27 | 2024-09-09 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-08-27 | 2024-09-09 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2024-08-27 | 2024-09-09 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2024-08-27 | 2024-09-09 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-04-27 | 2023-05-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-27 | 2023-05-20 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-09 | 2023-03-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-12-09 | 2023-02-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-12-09 | 2023-02-01 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-12-09 | 2023-01-31 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-12-09 | 2023-01-20 | 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 | 2022-12-09 | 2023-01-11 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-12-09 | 2023-01-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-09 | 2023-01-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-09 | 2023-01-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-12-09 | 2023-01-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-09 | 2023-01-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-09 | 2023-01-06 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-12-09 | 2023-01-06 | 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 | 2022-12-09 | 2023-01-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-09 | 2023-01-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-12-09 | 2023-01-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-10-07 | 2020-10-22 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2020-10-07 | 2020-10-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-10-07 | 2020-10-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-07 | 2020-10-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-10-07 | 2020-10-19 | N |
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