Health inspection·June 17, 2024

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, review of an emergency medical transportation record, review of facility policy, and interviews, the facility failed to provide goods and services to Resident #105 to prevent an incident of neglect resulting in the resident ' s death. This resulted in Immediate Jeopardy and actual harm/death beginning on [DATE] at approximately 8:18 P.M. when Resident #105, who had advance directives for a full code status was noted to exhibit behaviors and then subsequently requested (at around 12:00 A.M. on [DATE]) the use of an as needed bronchodilator (Albuterol) inhalation medication (used to treat or prevent bronchospasm and increase air flow to lungs) without further assessment or monitoring. On [DATE] at 12:37 A.M. Resident #105 was yelling and howling in his room; at which time Licensed Practical Nurse (LPN) #410 asked the resident to close his door. No additional assessment or monitoring of the resident was completed. State Tested Nursing Assistant (STNA) #450 delivered the resident ' s breakfast tray to his room at approximately 8:00 A.M. and assumed the resident was sleeping. On [DATE] at 8:30 A.M. LPN #339 assumed the resident was sleeping and did not attempt to wake the resident for medication administration or breakfast nor did the LPN return to provide care at any time prior to the resident being found deceased . There was no evidence LPN #339 administered the resident ' s morning medications as ordered, assessed Resident #105 or notified the physician Resident #105 had not taken his morning medication. On [DATE] at 12:30 P.M. STNA #359 delivered Resident #105 ' s lunch tray at which time it was identified the resident had not consumed any breakfast and the resident was not breathing. In addition, the resident was noted to have been in the same condition/position as when staff provided his breakfast tray. A code blue was called (for staff to initiate cardiopulmonary resuscitation (CPR)) and emergency medical services were called. The resident ' s pants were observed to be wet from urine and rigor mortis (postmortem rigidity, a recognizable sign of death that causes a person ' s body to stiffen. Rigor mortis begins as early as four hours after death and peaks around 12 hours) was noted to have occurred. CPR was ineffective and the resident was pronounced deceased by Emergency Medical Services (EMS). This affected one resident (#105) of four residents reviewed for death. The facility census was 102. On [DATE] at 10:02 A.M. the Administrator, Director of Nursing (DON), Mobile Operations Director #457, Regional Director of Operations #458 and Regional Director of Clinical Services #459 were notified Immediate Jeopardy began [DATE] when the facility failed to properly identify, assess and monitor a change in Resident #105 ' s condition. The lack of monitoring and overall cumulative effect of different individual failures in the provision of care and services by staff resulted in an environment of neglect for Resident #105. On [DATE] at approximately 12:30 P.M. staff identified the resident was not breathing; however, upon further investigation rigor mortis was identified resulting in CPR efforts being unsuccessful due to the amount of time the resident had been without oxygen and blood flow. The resident was pronounced deceased by EMS staff. (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 8 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 06/17/2024 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)