Health inspection·November 1, 2023

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #86's room was clean and sanitary. This affected one resident (Resident #86) out of three residents reviewed for clean and sanitary rooms. The facility census was 103. Findings include: Review of Resident #86's medical record revealed an admission date of 08/21/23 and diagnoses included delusional disorders, stage three pressure ulcers of right and left heels, and morbid obesity due to excess calories. Review of Resident #86's admission Minimum Data Set 3.0 assessment dated [DATE] revealed Resident #86 was cognitively intact. Resident #86 required extensive assistance of one staff member for bed mobility, limited assistance of one staff member for transfers and toilet use, and was not steady but able to stabilized without staff assistance when moving on and off the toilet. Review of Resident #86's care plan dated 08/23/23 included Resident #86 needed ADL (Activity of Daily Living) assistance related to cognitive impairment, immobility, pressure ulcers and multiple comorbidities. Resident #86 would be clean, odor-free and appropriately dressed on a daily basis. Resident #86 would be well-groomed and free of odors at all times and would participate as able in ADL self-care. Interventions included Resident #86 required non-weight bearing assistance including steadying, contact guard assistance, or guided maneuvering with transfers, dressing, toileting, and hygiene; staff would assist as needed with daily hygiene and would assist Resident #86 with showering per facility policy weekly. Observation on 10/31/23 at 11:06 A.M. of Resident #86 revealed she was lying in bed. Resident #86 stated things were not good at the facility. Resident #86 stated recently (she could not remember the exact day) she woke up about 3:40 A.M. and her right foot was bleeding and dripping on the floor. Resident #86 stated she put her call light on and it took over an hour for staff to answer it. Resident #86 pointed to the floor where her right foot dripped blood and an outline about two inches by three inches of what appeared to be dried blood was noted on the floor, and wipe marks could be seen on the floor around the dried blood mark on the floor. Resident #86 stated the bloody outline and wipe marks had been on the floor for about two days. Further observation of Resident #86's room revealed a bedside toilet against the wall under the call light system. The bedside toilet had a large amount of dark yellow urine and multiple pieces of toilet paper noted in it. Resident #86 stated the aides did not empty the bedside commode, and they would walk over to the call light, turn it off and ignore the urine in the bedside toilet. Resident #86 indicated it had been about two days since the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 6 Event ID: 365306 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madison Health Care 7600 S Ridge Rd Madison, OH 44057 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)