Inspection visit
Health inspection
9 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 9 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0602
Protect each resident from the wrongful use of the resident's belongings or money.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility
failed to ensure residents were free from misappropriation for one of 18 residents reviewed for
misappropriation (Resident #58).
Residents Affected - Few
The facility Maintenance staff took the gears off of Resident #58's personal specialty bariatric bed to repair
facility owned beds as discovered by Resident #58 when she attempted to sell her bed and the facility
informed her they had removed the gears for facility beds.
Failure to recognize and report misappropriation of resident property could lead to further misappropriation
which could lead to a decreased quality of life.
Findings included:
Review of Resident #58's Face Sheet reflected a [AGE] year old female admitted [DATE] with diagnoses of
Diabetes Mellitus, Malnutrition, Respiratory Failure and Morbid Obesity.
Review of Resident #58's Quarterly MDS dated [DATE] reflected a BIMS score of 11 which indicated
moderate cognitive impairment. Resident #58 was unable to ambulate independently in her room or in the
facility with the assistance of a wheel chair and extensive assistance from staff per Section G, Functional
Status.
Review of Resident #58's Comprehensive Care Plan dated 07/11/2019 reflected a focus of, Resident has
an ADL Self Care Performance Deficit, Interventions included, Discuss with resident/family/POA care any
concerns related to loss of independence, decline in function and Resident has a bariatric bed.
In an interview on 08/26/2019 at 11:30 AM, Resident #58 stated she had a bariatric bed at home and she
brought the bed with her when she entered the facility. She stated it was determined the bed would not
clear the doorway to the room so it would not be able to be used for safety reasons. She stated she put the
bed up for sale on a website in an effort to recoup funds spent on the bed. She stated when the buyer
contacted her to pick up the bed it was discovered her bed, which was stored at the facility was missing
parts. She was unable to sell her bed for this reason. Resident #58 further stated she had lost a brand new
television and lap top during the transfer of her property from one place to another. She stated some was
due to the renovations and some was she had too much property to fit into her room. She pays rent for
off-site storage but the television and the laptop had disappeared when the facility staff took her things out
of her room and put them in an unsecured area prior to getting them moved to the storage shed.
(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 22
Event ID:
675821
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
675821
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Madisonville Care Center
411 E Collard
Madisonville, TX 77864
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)
F 0602
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
In an interview on 08/27/2019 at 08:23 AM, the Maintenance Supv stated he discovered the gears were
missing from the bed in question when Resident #58 notified him she had a buyer for the bed. He stated
the gears were removed to repair a facility owned bed as they all used the same type of gears.
In an interview on 08/28/2019 at 05:27 PM, the ADM stated Resident #58 was not asked permission prior
to removing the gears from her bed to repair a facility owned bed. the ADM further stated the alleged theft
of Resident #58's property had been self-reported as misappropriation and the facility was unable to
determine who had taken the laptop and television from the unlocked room the facility staff had put the new
television and laptop in.
Review of policy, Exploitation and Misappropriation of Funds, undated, reflected, The facility takes
exploitation and misappropriation of funds very seriously. It is our guarantee that we will protect our
residents in every way possible from theft, fraud and abuse.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675821
If continuation sheet
Page 2 of 22
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
675821
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Madisonville Care Center
411 E Collard
Madisonville, TX 77864
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)
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to ensure a resident who was unable to carry out
activities of daily living received the necessary services to maintain good nutrition for one (1) of six (6)
residents reviewed for activity of daily living assistance (Residents #54).
Residents Affected - Few
The facility failed to ensure Resident #54 was receiving assistance or supervision with feeding at meals.
This failure could lead to loss of dignity and weight loss.
Findings included:
Record Review of Resident #54's Face Sheet reflected, [AGE] year-old male admitted on [DATE] with
diagnoses of: Moderate Intellectual Disabilities, Unspecified Glaucoma, Contracture Unspecified Joint,
Restlessness and Abnormal Weight Loss.
Record Review of Resident #54's Annual MDS dated [DATE] reflected, BIMS score of 0. He had not
refused assistance and required extensive assistance with eating.
Record Review of Resident #54's Care Plan revision on 08/26/19 reflected, Resident has an ADL self-care
Performance Deficit. Intervention Eating: supervision as needed (initiated on 10/02/18). The resident has
impaired visual function related to Glaucoma. Interventions: Arrange Consultation with eye care practitioner
as required. Monitor/ Document report to MD change in ability to perform ADLs. Care Plan didn't reflect
interventions of posture during meal times or eating with hands.
Record Review of Resident #54's Physician Order dated 08/27/2019 reflected, Regular Diet Mechanical
Soft texture, Regular Consistency.
Observation of Meal Service on 08/26/2019 at 12:40 PM revealed, Staff feeding Resident #54. The staff in
dining room related Resident #54 does require assistance with feeding.
Observation of Meal Service on 08/26/2019 at 5:25 PM revealed Resident #54 was being fed by staff in his
room.
Observation of Meal Service on 08/27/19 at 7:30 AM revealed, Resident #54's chin was on table when
using hands to eat his oatmeal and eggs. Staff didn't attempt to reposition him, offer assist with feeding or
provide any supervision/cueing during breakfast meal.
Observation of Meal Service on 08/27/2019 at 12:40 PM revealed, Resident #54 leaned forward with face
next to his plate. Resident #54 was eating sautéed zucchini and veal parmesan with his hands. Staff
didn't assist him with feeding, didn't reposition him or provide any supervision/cueing during lunch meal.
Observation of Meal service on 08/28/2019 at 07:35 AM revealed, Resident #54's chin touching the table.
He was eating eggs and oatmeal with his hands. Staff didn't assist with feeding, provide any
supervision/cueing or reposition him during breakfast meal.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675821
If continuation sheet
Page 3 of 22
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
675821
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Madisonville Care Center
411 E Collard
Madisonville, TX 77864
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)
F 0677
Level of Harm - Minimal harm
or potential for actual harm
In an interview on 08/26/2019 at 5:29 PM LVN K stated, He (Resident #54) does need assistance with
feeding he leans and has problems seeing food sometimes.
In an interview on 08/27/2019 at 03:39 PM the Director of Nurses stated, the staff is to feed him and to
reposition. (Resident #54)
Residents Affected - Few
In an interview on 08/28/2019 at 08:18 AM CNA H stated, He (Resident #54) has help from staff with his
feeding we were told reposition him (Resident #54) when he leans forward with head downward and body
downward close to knees allot sitting in wheelchair.
In an interview on 08/28/2019 at 01:36 PM LVN J stated, I believe he (Resident #54) is to have assistance
with feeding and reposition when leans forward.
Record Review of Facility Policy of Feeding/ Assistive/ Complete reflected, Assistive or complete feeding of
meals is provided to residents who have decreased appetites or are unable to eat independently because
of disabilities, confusion, weakness, neuromuscular disorders. The amount of assistance needed can vary
or be temporary.
Goals:
2. The Resident will receive optimal nutritional intake with partial or complete assistance.
5. Position the resident for comfort.
10. b. Arrange the dishes for easy access.
Record review of undated Facility Policy on Comprehensive Care Planning revealed, The comprehensive
care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the
specific care and services that will be implemented. When developing the comprehensive care plan, facility
staff will, at a minimum, use the MDS to assess the resident's clinical condition, cognitive and functional
status, and use of services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675821
If continuation sheet
Page 4 of 22
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
675821
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Madisonville Care Center
411 E Collard
Madisonville, TX 77864
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)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to ensure that residents received treatment and
care in accordance with professional standards of practice and a comprehensive person-centered care plan
for two of six residents reviewed for quality of care (Residents #23 and #67).
Residents Affected - Some
The facility failed to ensure;
A. Resident #23 received her restorative treatment 6 times per week per her care plan and failed to ensure
she wore geri-sleeves at all times per care plan.
B. Resident #67 routinely received his re-positioning per care plan when he did not get repositioned on
08/27/2019 and 08/29/2019.
These failures could lead to falls with significant injuries, declines in range of motion and a decreased
quality of life.
Findings Included:
A. Review of Resident #23's Face Sheet reflected a [AGE] year-old female admitted on [DATE] with
diagnoses including: Cerebral Infarction, Hemiplegia and Hemiparesis following Cerebral Infarction affecting
Left Non-Dominant Side and History of Falling.
Review of Resident #23's Quarterly MDS dated [DATE] reflected the resident rarely/ never understood,
requires extensive assistance with ADL Care and was at risk for and skin injuries.
Review of Resident #23's Care Plan dated 06/17/2019 reflected, Resident often bites fingers/ hands and
will swing arms around at times. Interventions included, Resident to wear geri-sleeves at all times. Resident
has Hemiplegia/ Hemiparesis related to Cerebral Infarction. Interventions included: Resident on restorative
program six (6) times per week.
Review of Resident #23's Physician Orders dated 8/28/2019 reflected, May apply Geri Sleeves to Left arm
for skin protection.
Record Review of Resident #23's Restorative Record dated 2019 reflected;
May- missed 3 days one week and missed 1 day one week.
June- missed 1 day one week.
July- missed 1 days one week, missed 1 day one week and missed one day one week
August- missed 1 day one week, missed 4 days one week and missed 1 day one week.
Observation of Resident #23 revealed she wasn't wearing geri-sleeves at the following times:
08/27/2019- on eleven (11) different occasions.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675821
If continuation sheet
Page 5 of 22
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
675821
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Madisonville Care Center
411 E Collard
Madisonville, TX 77864
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)
F 0684
08/28/2019- on ten (10) different occasions.
Level of Harm - Minimal harm
or potential for actual harm
In an interview on 08/27/2019 at 02:14 PM LVN K stated, Yes, geri sleeves to be on her (Resident #23) at
all times. She does hit her arms on things and will bite her arms.
Residents Affected - Some
In an interview on 08/27/2019 at 3:15 PM Restorative Aide stated, Resident
(Resident #23) has orders to receive restorative therapy six (6) times per week.
In an interview on 08/28/2019 at 08:14 AM CNA H stated, Resident (Resident #23) is supposed to wear
geri-sleeves on arms at all times.
In an interview on 08/28/2019 at 03:12 PM the Director of Nurses stated, I am not sure, I would need to
look at her care plan when asked about Resident #23's geri- sleeves.
B. Review of Resident #54's Face Sheet reflected, A [AGE] year-old male admitted on [DATE] with
diagnoses including: Moderate Intellectual Disabilities, Unspecified Glaucoma, Restlessness, Abnormal
Weight Loss.
Review of Resident #54's Annual MDS dated [DATE] reflected, Resident requires extensive assistance with
eating. Resident ADL's requires extensive assistance. Resident BIMS Cognition is 0- severely impaired.
Review of Resident #54's Care Plan dated 08/26/2019 reflected, Resident has had falls. Interventions:
Nursing Staff to check his activities in room and positioning while on chair and on bed, re-position when
seen leaning forward and sideways. Nursing Staff to check and monitor his mobility and positioning while
sitting on wheelchair. Staff to anticipate and check his needs before lunchtime. Alteration in musculoskeletal
status related to contracture of spine. Intervention: The Resident needs to change position at least every 2
hours. Alternate periods of rest with activity out of bed to prevent respiratory complications, dependent
edema, flexion deformity and skin pressure areas. Resident has impaired visual function related to
Glaucoma. Interventions didn't reflect difficulty seeing his food.
Record Review of Resident #54's Physician Orders for August 2019 reflected, no changes in medications.
Record Review of #54 Pharmacy Report Records for August 2019 reflected, no changes in medications.
Observation of Resident #54 positioning revealed on:
08/27/19 at 07:30 AM Resident #54's chin was on table while eating. He was using his hands to feed
himself. Staff didn't assist with repositioning, feeding or cue him during meal.
08/27/19 at 08:30 AM Resident #54 leaning forward sitting in his wheelchair. Staff sitting near resident and
didn't reposition him.
08/27/19 at 10:30 AM Resident #54 sitting in his wheelchair with head on his knees- staff standing near him
and didn't reposition him.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675821
If continuation sheet
Page 6 of 22
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
675821
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Madisonville Care Center
411 E Collard
Madisonville, TX 77864
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)
F 0684
08/27/19 at 11:00 AM Resident #54 head on his knees- staff near Resident and didn't reposition him.
Level of Harm - Minimal harm
or potential for actual harm
08/27/19 at 11:30 AM Resident #54 leaning forward and head almost on his knees - staff standing near him
and didn't reposition him.
Residents Affected - Some
08/27/19 at 12:05 PM Resident #54 chin was on dining room table. Staff didn't reposition him.
08/27/19 at 12:45 PM Resident #54 face was next to his plate and was eating with his hands. Staff
observed him and didn't reposition him or offer assistance with cueing or feeding.
08/27/19 at 01:05 PM Resident #54 head on his lap- there were staff standing near him and didn't offer to
reposition him.
08/27/19 at 02:00 PM Resident #54 leaning forward while sitting in his wheelchair his head was almost in
his lap. The staff near him and didn't reposition him.
08/27/19 at 03:00 PM Resident #54 sitting in his wheelchair leaning forward. His face was in his lap- staff
walked by and spoke to him. Staff didn't reposition him.
08/27/19 at 04:00 PM Resident #54 leaning forward in his wheelchair. His face was touching his knees.
Staff observed Resident and didn't reposition him.
08/28/19 at 07:35 AM Resident #54 sitting in wheelchair with chin touching table in dining room. He was
eating with his hands. Staff didn't offer to assist with reposition, cueing or feeding.
08/28/19 at 08:16 AM Resident #54 sitting in wheelchair leaning forward. Resident's head touching his
knees. Staff standing near him didn't reposition him.
08/28/19 at 08:51 AM Resident #54 sitting in wheelchair leaning forward with head almost touching his
knees. Staff standing near him and didn't reposition him.
08/28/19 at 09:50 AM Resident #54 sitting in wheelchair leaning forward with his head almost touching his
knees. Staff sitting near him didn't offer to reposition him.
08/28/19 at 10:45 AM Resident #54 sitting in wheelchair leaning forward with his head almost touching his
knees. Staff standing near him and didn't reposition him.
08/28/2019 at 11:50 AM Resident #54 sitting in wheelchair leaning forward with head almost touching his
knees. Staff standing near him didn't reposition him.
08/28/2019 at 12:15 PM Resident #54 sitting in wheelchair with chin on table. Resident eating with his
hands. Staff didn't offer assistance with repositioning, feeding or cueing resident.
08/28/2019 at 01:25 PM Resident #54 sitting in wheelchair in dining room with chin on table. Staff standing
near him and didn't reposition him.
08/28/19 at 02:39 PM Resident #54 sitting in wheelchair leaning forward near table in dining room with
head on knees. Staff in dining room and didn't reposition him.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675821
If continuation sheet
Page 7 of 22
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
675821
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Madisonville Care Center
411 E Collard
Madisonville, TX 77864
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)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
08/28/19 at 03:00 PM Resident #54 sitting in wheelchair with head on dining room table. Staff in dining
room didn't reposition him.
In an interview on 08/27/19 at 03:39 PM the Director of Nurses stated, We have reviewed his (Resident #
54) medications for interventions for August and when staff sees him (Resident#54) leaning they are to
reposition him. He received a special wheel chair a few months ago. Staff are to feed him.
In an interview on 08/28/19 at 08:18 AM CNA H stated, He (Resident #54) needs help with feeding. We
were told by nurses to reposition him (Resident #54) if he leans.
In an interview on 08/28/19 at 1:36 PM LVN J stated, He (Resident #54) is to have assistance from staff
with feeding. Staff are to reposition if he (Resident #54) leans forward.
Record Review of the undated Policy Positioning reflected positioning and repositioning in the wheelchair
was not addressed.
Record review of undated Policy Comprehensive Care Planning revealed, The comprehensive care plan will
reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care
and services that will be implemented. When developing the comprehensive care plan, facility staff will, at a
minimum, use the MDS to assess the resident's clinical condition, cognitive and functional status, and use
of services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675821
If continuation sheet
Page 8 of 22
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
675821
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Madisonville Care Center
411 E Collard
Madisonville, TX 77864
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)
F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to ensure a resident was offered a therapeutic
diet when there was a nutritional problem and the health care provider ordered a therapeutic diet for one of
six reviewed for therapeutic diets (Resident #43).
Residents Affected - Few
Resident #43 had a significant weight loss and was not served his physician ordered large portions on
08/26/2019 at lunch and supper.
This failure could lead to continued weight loss and a decline in health status.
Findings included;
Review of Resident #43's Face Sheet reflected he was a [AGE] year old male admitted on [DATE] with the
diagnosis of Dementia.
Review of Resident #43's Annual MDS dated [DATE] reflected he had a BIMS of two which indicated severe
cognitive impairment, he wandered on the unit, and he required extensive assistance of one person for
eating. The 07/14/2019 MDS reflected Resident #43 weighed 184 pounds and had a significant unplanned
weight loss during the six months prior to the 07/14/2019 MDS.
Review of Resident #43's Care Plan reflected he had a significant unexpected weight loss and he was to
receive supplements, have a red glass on his tray to identify him to staff as possibly needing assistance,
encouragement and substitutes and his weight was to be monitored. The care plan did not reflect he had an
order for large portions.
Review of Resident #43's Weight sheet reflected;
05/07/2019 196.5
06/10/2019 200
07/11/2019 184 (8% weight loss from 06/10/2019)
08/16/2019 180.5
Review of Resident #43's Physician orders reflected a diet order dated 9/19/2018 for; No salt on tray,
Regular texture, Regular consistency, large portions; Red Glass. An order dated 07/20/2019 reflected he
was to receive a high calorie supplement four times a day for weight loss and an order dated 09/11/2018
reflected he was to reside on the secure unit due to his elopement risk.
Observation on 08/26/19 12:23 PM reflected the trays had been served on the secure unit and Resident
#43's serving size was no different from all the other residents. He received the same portion of; Mississippi
Chicken, one scoop of rice, one biscuit, one margarine, one bowl of zucchini and tomatoes and one cup
cake. He received a glass of water and tea.
In an interview on 08/26/2019 LVN E was asked why Resident #43's portions were the same as everyone
else's and she stated the residents (in general) were, Not going to eat their full meal anyway.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675821
If continuation sheet
Page 9 of 22
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
675821
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Madisonville Care Center
411 E Collard
Madisonville, TX 77864
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)
F 0692
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Observation of meal tray preparation on 8/26/2019 at 5:20 PM revealed [NAME] B did not read the diet
slips as she prepared 16 trays in succession.
Observation on 08/26/19 at 5:49 PM revealed Resident #43 had a sloppy joe (which he took apart to reveal
the normal amount of meat), a bowl of mixed vegetables and sweet potato fries along with a chocolate chip
cookie, water and tea. the tray did not reflect he had large portions. Resident #43 was not eating his meal
but was moving it around.
In an interview on 08/26/2019 at 5:50 PM CNA G stated there was no difference in Resident #43's tray and
the other trays.
Observation on 08/26/19 at 6:00 PM revealed CNA G assisted Resident #43 with his meal which had been
replaced with large portions. Resident #43 was not eating until CNA G began to feed him.
Observation rounds on Hall C on 08/26/19 at 6:36 PM with the Regional RN revealed resident starch
portion sizes were not consistent in general on the supper trays on hall C.
In an interview on 08/28/19 at 5:13 PM the DON stated Resident #43 should have received large portions
as ordered.
Review of the policy Large Portions dated 2012 reflected; We will add extra calories and protein to the
regular diet as appropriate. Serve the diet per the menu with additional foods as indicated: Lunch and
dinner; desserts per regular portions, 2 x the entrée portion, 2x the bread portion, 2x the margarine
and eight ounces of milk. Other meats, cheese or cottage cheese may be substituted to provide the large
portion as required.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675821
If continuation sheet
Page 10 of 22
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
675821
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Madisonville Care Center
411 E Collard
Madisonville, TX 77864
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)
F 0710
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure the medical care of each resident was
supervised by a physician for one (1) of 18 Residents reviewed for supervision of medical care by a
physician (Resident #18).
Residents Affected - Few
The facility did not notify Resident #18's physician when her weights revealed a loss of over 10% between
May 16, 2019 and June 18, 2019.
This failure could affect residents who had unplanned weight loss by not ensuring that residents' care was
provided by a physician who was knowledgeable of their current health status changes.
Findings included:
Review of Resident #18's Face Sheet reflected a [AGE] year old female admitted [DATE] with a diagnoses;
Nausea with Vomiting, Vitamin D Deficiency, GERD, Major Depressive Disorder, Type 2 Diabetes Mellitus
with Hyperglycemia and Dysphagia, Oropharyngeal.
Review of Resident #18's Quarterly MDS dated [DATE] reflected a BIMS score of 4 indicating severe
cognitive impairment. Section G, Functional Status reflected she required extensive assistance with eating
and the assistance of as least one staff person. Section K, Swallowing/Nutritional Status reflected she had
a significant weight loss and was not on a physician-prescribed weight-loss regimen.
Review of Resident #18's Comprehensive Care Plan dated 06/17/2019 reflected a focus of, The resident
has a significant unplanned/unexpected weight loss. Interventions included, Notify the physician, resident
and family of the weight loss.
Review of Resident #18's weights:
05/07/2019
155 LBS
05/16/2019
145 LBS
06/18/2019
130 LBS
06/26/2019
136.2 LBS
Review of Resident's Social Service Progress Notes dated 04/29/2019 reflected Resident #18's son stated,
.she likes going to hospital that she felt that food is better and she has her own room and better cable and
someone to feed her that she enjoys it
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675821
If continuation sheet
Page 11 of 22
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
675821
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Madisonville Care Center
411 E Collard
Madisonville, TX 77864
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)
F 0710
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Review of Resident #18's Weight Watchers form effective 05/14/2019 reflected a weight loss of 10 pounds
and that the doctor and the resident were notified of the weight loss on 05/14/2019. The form further
reflected; Assistance required when eating: verbal cueing only.
Review of Resident #18's Weight Watchers form effective 06/18/2019 reflected a weight loss of 15 pounds.
There was no documentation that the doctor or resident was notified. Question No. 13 Was the physician
notified of any negative changes? No.
In an interview and observation on 08/26/2019 at 10:13 AM Resident #18 stated the staff was sending her
strawberry shakes but she did not like them, she would rather have banana nut but the facility doesn't have
that flavor. She stated she received puree meals but doesn't like the texture and doesn't feel like eating
often. Resident was feeding herself with a large handled spoon.
In an interview on 08/28/2019 at 3:05 PM the DON stated in response to Resident #18's weight loss, the
facility reviewed her medication, her diagnoses, recent hospitalizations and checked the scale to ensure it
was calibrated correctly. She stated a program called Weight Watchers was used to track resident weight
loss.
In an interview on 08/28/2019 at 05:49 PM the DON stated Resident #18's doctor was notified of her weight
loss of 15 pounds between May 16, 2019 and June 18, 2019 but she could not provide documentation to
support her statement.
Policy regarding weight loss management was not provided prior to exit.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675821
If continuation sheet
Page 12 of 22
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
675821
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Madisonville Care Center
411 E Collard
Madisonville, TX 77864
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)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review the facility failed to ensure the pharmacist provided consultation
on all aspects of the provision of pharmacy services in the facility for four of 18 residents reviewed for
psychoactive drugs (Residents #46, #40, #62 and #45), one of two medication carts (Hall A) and two of two
medication refrigerators reviewed (Hall A and Hall B) when:
Four residents with psychoactive medication orders did not have a 14 day stop date and did not have letters
to or from the physician with rationale for continuing the psychoactive drugs:
A. Resident #45 was ordered Haloperidol Lactate (anti-psychotic Medication) 2 mg/ml by mouth every 6
hours PRN initiated 07/19/2019 and Lorazepam (anti-anxiety Medication) 0.5 mg by mouth every 4 hours
PRN initiated 07/19/2019 without a stop date.
B. Resident #46 was ordered Lorazepam (anti-anxiety Medication) 0.5 mg by mouth every 6 hours PRN
initiated 07/09/2019 without a stop date.
C. Resident #40 was ordered Ativan (anti-anxiety Medication) 1 mg by mouth every 4 hours PRN initiated
06/08/2019 without a stop date.
D. Resident #62 was ordered Lorazepam (anti-anxiety Medication) 0.5 mg by mouth every 6 hours PRN
initiated 06/11/2019 without a stop date.
This failure affected four residents and could affect additional resident receiving PRN Psychotropic
medications by receiving unnecessary medications for an extended period.
E. 1. Resident #23 had 22 Phenobarbital 64.8 mg dated 03/01/2019 for which had been discontinued for
the second time on 03/15/2019 and was still on the cart and was administered on 04/08/2019 after it was
discontinued. 2. The Hall A Nurse medication cart had a card of 26 Apap/Codeine 300 mg - 30 mg tablets
delivered on 06/14/2019 for Resident #42 and there was no count sheet for the controlled narcotic
medication readily available. 3. Resident #45 had a card of 28 Clonazepam 0.5 mg tablets delivered on
03/15/2019 and a bottle of two Clonazepam 0.5 mg tablets delivered on 03/15/2019, they had been
discontinued on 04/02/2019 and remained on the cart.
F. The B hall refrigerator had an opened multi-use vial of Purified Protein Tuberculin derivative that was not
labeled with an expiration date. The A hall refrigerator had an opened multi-use vial of Purified Protein
Tuberculin derivative with an opened date of May 2019 and no expiration date. The Pharmacist report for
July and August 2019 did not reflect the pharmacist had reviewed the refrigerators and ensured expired
drugs were discarded.
Findings included:
A. Review of Resident #45's Face Sheet reflected a [AGE] year old male admitted [DATE] with diagnosis of
Major Depressive Disorder.
Review of Resident #45's Significant Change MDS dated [DATE] reflected a BIMS score of 03 indicating a
severe cognitive deficit.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675821
If continuation sheet
Page 13 of 22
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
675821
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Madisonville Care Center
411 E Collard
Madisonville, TX 77864
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)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Review of Resident #45's current Order Summary Report reflected an order for the anti-psychotic
medication Haloperidol Lactate Concentrate 2 mg/ml. Give 1 ml by mouth every 6 hours as needed for
agitation. Order initiated 07/19/2019 with no end date. An additional order for Lorazepam 0.5 MG Give 1
tablet by mouth every 4 hours as needed for agitation. Order initiated 07/19/2019 with no end date.
B. Review of Resident #46's Face Sheet reflected an [AGE] year old female admitted [DATE] with
diagnoses of Dementia without Behavioral Disturbance, Anxiety Disorder, Major Depressive Disorder and
Alzheimer's Disease.
Review of Resident #46's Significant Change MDS dated [DATE] reflected a BIMS score of 12 indicating
she was cognitively intact.
Review of Resident #46's Comprehensive Care Plan dated 08/05/2019 reflected focus of, The resident
uses anti-anxiety medications PRN r/t (related to) Anxiety disorder. Interventions included, Give anti-anxiety
medications ordered by physician. Monitor/document side effects and effectiveness.
Review of Resident #46's current Order Summary Report dated 08/2019 reflected an order for Lorazepam
Tablet 0.5 MG Give 1 tablet by mouth every 6 hours as needed for Anxiety. Order initiated 07/09/2019 with
no end date.
C. Review of Resident #40's Face sheet reflected an [AGE] year old female admitted [DATE] with diagnoses
of Major Depressive Disorder, Delusional Disorders, Dementia in other Diseases with Behavioral
Disturbance and Unspecified Psychosis not due to a Substance or Known Physiological Condition
Review of Resident #40's Significant Change MDS dated [DATE] reflected a BIMS score of 00 indicating a
severe cognitive deficit.
Review of Resident #40's Comprehensive Care Plan dated 05/17/2019 reflected focus of, The resident
uses anti-anxiety medications PRN r/t Anxiety disorder, Interventions included, Give anti-anxiety
medications ordered by physician. Monitor/document side effects and effectiveness.
Review of Resident #40's current Order Summary Report dated 08/2019 reflected an order for Ativan Tablet
1 MG Give 1 tablet by mouth every 4 hours as needed for Anxiety / Agitation. Order initiated 06/08/2019
with no stop date.
D. Review of Resident #62's Face Sheet reflected an [AGE] year old female admitted [DATE] with
diagnoses of Anxiety Disorders, Dementia without Behaviors and Major Depressive Disorders.
Review of Resident #62's Significant Change MDS dated [DATE] reflected a BIMS score of 03 indicating a
severe cognitive deficit.
Review of Resident #62's Comprehensive Care Plan dated 05/02/2019 reflected focus of, The resident
uses anti-anxiety medications PRN r/t Anxiety disorder. Interventions included, Give anti-anxiety
medications as ordered by physician. Monitor/document side effects and effectiveness.
Review of Resident #62's current Order Summary Report dated 08/2019 reflected an order for Lorazepam
0.5 MG Give 1 tablet by mouth every 6 hours as needed for Anxiety. Order initiated 06/11/2019 with no end
date.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675821
If continuation sheet
Page 14 of 22
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
675821
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Madisonville Care Center
411 E Collard
Madisonville, TX 77864
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)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Review of Resident charts for Residents #45, #46, #40 and #62 reflected there were no letters from the
pharmacist requesting rationale for continuing the psychoactive drugs and there were no letters from the
physicians which provided rationale to continue the psychoactive drugs beyond the 14 day period.
In an interview on 08/28/2019 at 5:27 PM, the DON stated her expectation regarding orders for
psychoactive drugs over 14 days was for them to be reviewed and correlate with the doctor to see if they
can be discontinued or the order changed.
Review of policy, Psychotropic Drugs dated 2003 Revised 10/25/2017 revealed, The facility will ensure that
. 6. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending
physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
E. 1. Review of the Hall A medication cart reflected a card of 22 Phenobarbital 64.8 mg dated 03/01/2019
for Resident #23 which was last administered on 04/08/2019 according to the count sheet. The card
reflected, Phenobarb tab 64.8 mg give one tablet by mouth every six hours as needed for anxiety for 14
days. There were no directions change sticker to indicate the 14 days had been extended.
Review of Resident #23's orders reflected it had been discontinued for the second time on 03/15/2019 and
was still on the cart (which enabled LVN U to administer it on 03/27/19, 03/28/19, 03/29/19, 04/07/19, and
04/08/19).
2. Observation of the Hall A medication cart on 08/28/2019 at 2:30 PM reflected there was a card of 26
Apap/Codeine 300 mg - 30 mg tablets delivered on 06/14/2019 for Resident #42 and there was no count
sheet for the controlled narcotic medication. The card label reflected 30 tablets had been delivered to the
facility.
In an interview on 08/28/19 at 2:47 PM LVN T stated he did not know where the count sheet was for
Resident #42's Apap/Codeine 300 mg - 30 mg tablets. LVN T stated he had been on vacation and couldn't
say whether the count sheet had been with the card or how long it had been missing.
In an interview/observation on 08/28/2019 at the Regional RN stated Resident #42's count sheet had been
located in a MAR book on the unit where Resident #42 used to live more than several days previously.
3. Further review of the Hall A medication cart on 08/28/2019 at 2:30 PM reflected Resident #45 had a card
of 28 Clonazepam 0.5 mg tablets delivered on 03/15/2019 and a bottle of two Clonazepam 0.5 mg tablets
delivered on 03/15/2019 and they had not been used since 03/15/2019. (Clonazepam-a tranquilizer of the
benzodiazepine class.)
Review of Resident #45's Physician orders reflected Resident #45's Clonazepam had been discontinued on
04/02/2019 yet it was not removed from the cart and was still available to staff.
F. Observation on 08/28/2019 at 2:15 PM revealed the Hall B medication refrigerator had an opened
multiuse vial of Purified Protein Tuberculin derivative that was not dated when it was opened.
In an interview on 08/28/19 at 2:15 PM LVN S stated the Tuberculin derivative should have been dated
when it was opened.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675821
If continuation sheet
Page 15 of 22
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
675821
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Madisonville Care Center
411 E Collard
Madisonville, TX 77864
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)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Observation on 08/28/19 at 02:37 PM revealed LVN T stated the Tuberculin derivative should have been
dated when it was opened.
In an interview on 08/28/19 at 3:00 PM the DON stated the Tuberculin derivative should have been dated
when it was opened, and it should have been disposed of 30 days after it was opened.
Residents Affected - Some
Review of the website: https://www.fda.gov/media/74866/download on 08/30/2019 reflected: STORAGE
A vial of TUBERSOL (purified protein derivative) which has been entered and in use for 30 days should be
discarded. Do not use after expiration date.
Review of the Pharmacy Reports dated July 29, 2019 reflected the failures had not been identified/rectified.
In an interview on 08/28/19 at 3:00 PM the DON stated she expected her staff to count the controlled drugs
every shift (therefore the count sheet for Resident #42's Apap/Codeine 300 mg - 30 mg tablets should have
been with drugs). The DON stated the discontinued medications should have been brought to the DON's
office as soon as they were discontinued. When asked if the pharmacist should have been noting to her
that medications were on the cart past the effective order date, multiuse vials were not dated when opened
and count sheets were not with the controlled medication she stated the Pharmacist came every month and
the DON was appreciative of the job the Pharmacist did.
In an interview on 08/28/19 at 5:13 PM the Regional RN stated he would fully audit three medication carts
for compliance.
Review of the policy Storage and Documentation of Schedule II Controlled Medications dated 2003
reflected All Schedule II controlled medications will be stored under double lock and checked for
accountability at each change of shift by the nurse going off duty and the nurse coming on duty. In the event
that a discrepancy is noted, the nurse shall contact the DON and Consultant Pharmacist. Disposition of
controlled substances is maintained on a sheet supplied by the Pharmacy with each II, III and IV
substance. Review of the policy Medication Storage Recommendations with no date reflected the Purified
Protein Derivative (Tuberculin) multi use vials expire 30 days after the initial use.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675821
If continuation sheet
Page 16 of 22
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
675821
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Madisonville Care Center
411 E Collard
Madisonville, TX 77864
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)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure PRN (as needed) orders for psychoactive drugs
were limited to 14 days, and that the attending physician documented their rationale in the resident's
medical record indicating the duration for the PRN order for four of 18 residents reviewed for unnecessary
medications. (Resident #'s 46, 40, 62 and #45)
A. Resident #45 was ordered Haloperidol Lactate (anti-psychotic Medication) 2 mg/ml by mouth every 6
hours PRN initiated 07/19/2019 and Lorazepam (anti-anxiety Medication) 0.5 mg by mouth every 4 hours
PRN initiated 07/19/2019 without a stop date.
B. Resident #46 was ordered Lorazepam (anti-anxiety Medication) 0.5 mg by mouth every 6 hours PRN
initiated 07/09/2019 without a stop date.
C. Resident #40 was ordered Ativan (anti-anxiety Medication) 1 mg by mouth every 4 hours PRN initiated
06/08/2019 without a stop date.
D. Resident #62 was ordered Lorazepam (anti-anxiety Medication) 0.5 mg by mouth every 6 hours PRN
initiated 06/11/2019 without a stop date.
This failure could affect residents receiving PRN Psychotropic medications by receiving unnecessary
medications for an extended period.
Findings include:
A. Review of Resident #45's Face Sheet reflected a [AGE] year old male admitted [DATE] with diagnosis of
Major Depressive Disorder.
Review of Resident #45's Significant Change MDS dated [DATE] reflected a BIMS score of 03 indicating a
severe cognitive deficit.
Review of Resident #45's current Order Summary Report reflected an order for the anti-psychotic
medication Haloperidol Lactate Concentrate 2 mg/ml. Give 1 ml by mouth every 6 hours as needed for
agitation. Order initiated 07/19/2019 with no end date. An additional order for Lorazepam 0.5 MG Give 1
tablet by mouth every 4 hours as needed for agitation. Order initiated 07/19/2019 with no end date.
B. Review of Resident #46's Face Sheet reflected an [AGE] year old female admitted [DATE] with
diagnoses of Dementia without Behavioral Disturbance, Anxiety Disorder, Major Depressive Disorder and
Alzheimer's Disease.
Review of Resident #46's Significant Change MDS dated [DATE] reflected a BIMS score of 12 indicating
she was cognitively intact.
Review of Resident #46's Comprehensive Care Plan dated 08/05/2019 reflected focus of, The resident
uses anti-anxiety medications PRN r/t (related to) Anxiety disorder. Interventions included, Give anti-anxiety
medications ordered by physician. Monitor/document side effects and effectiveness.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675821
If continuation sheet
Page 17 of 22
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
675821
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Madisonville Care Center
411 E Collard
Madisonville, TX 77864
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)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Review of Resident #46's current Order Summary Report dated 08/2019 reflected an order for Lorazepam
Tablet 0.5 MG Give 1 tablet by mouth every 6 hours as needed for Anxiety. Order initiated 07/09/2019 with
no end date.
C. Review of Resident #40's Face sheet reflected an [AGE] year old female admitted [DATE] with diagnoses
of Major Depressive Disorder, Delusional Disorders, Dementia in other Diseases with Behavioral
Disturbance and Unspecified Psychosis not due to a Substance or Known Physiological Condition
Review of Resident #40's Significant Change MDS dated [DATE] reflected a BIMS score of 00 indicating a
severe cognitive deficit.
Review of Resident #40's Comprehensive Care Plan dated 05/17/2019 reflected focus of, The resident
uses anti-anxiety medications PRN r/t Anxiety disorder, Interventions included, Give anti-anxiety
medications ordered by physician. Monitor/document side effects and effectiveness.
Review of Resident #40's current Order Summary Report dated 08/2019 reflected an order for Ativan Tablet
1 MG Give 1 tablet by mouth every 4 hours as needed for Anxiety / Agitation. Order initiated 06/08/2019
with no stop date.
D. Review of Resident #62's Face Sheet reflected an [AGE] year old female admitted [DATE] with
diagnoses of Anxiety Disorders, Dementia without Behaviors and Major Depressive Disorders.
Review of Resident #62's Significant Change MDS dated [DATE] reflected a BIMS score of 03 indicating a
severe cognitive deficit.
Review of Resident #62's Comprehensive Care Plan dated 05/02/2019 reflected focus of, The resident
uses anti-anxiety medications PRN r/t Anxiety disorder. Interventions included, Give anti-anxiety
medications as ordered by physician. Monitor/document side effects and effectiveness.
Review of Resident #62's current Order Summary Report dated 08/2019 reflected an order for Lorazepam
0.5 MG Give 1 tablet by mouth every 6 hours as needed for Anxiety. Order initiated 06/11/2019 with no end
date.
Review of Resident charts for Residents #45, #46, #40 and #62 reflected there were no letters from the
pharmacist requesting rationale for continuing the psychoactive drugs and there was no letters from the
physicians which provided rationale to continue the psychoactive drugs beyond the 14 day period.
In an interview on 08/28/2019 at 5:27 PM, the DON stated her expectation regarding orders for
psychoactive drugs over 14 days was for them to be reviewed and correlate with the doctor to see if they
can be discontinued or the order changed.
Review of policy, Psychotropic Drugs dated 2003 Revised 10/25/2017 revealed, The facility will ensure that
. 6. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending
physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675821
If continuation sheet
Page 18 of 22
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
675821
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Madisonville Care Center
411 E Collard
Madisonville, TX 77864
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)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
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.
Based on observation, interview and record review the facility failed to ensure drugs and biologicals used in
the facility were labeled with cautionary instructions or the expiration date for two vials of opened Purified
Protein Tuberculin derivative.
The B hall refrigerator had an opened multi-use vial of Purified Protein Tuberculin derivative that was not
labeled with an expiration date. The A hall refrigerator had an opened multi-use vial of Purified Protein
Tuberculin derivative with an opened date of May 2019 and no expiration date.
This failure to label medications with the expiration date led to the opened medications remaining available
for use which could have led to a failure of the derivative to identify a staff or resident that may have had a
positive tuberculosis reaction.
Findings included;
Observation on 08/28/2019 at 2:15 PM revealed the Hall B medication refrigerator had an opened multiuse
vial of Purified Protein Tuberculin derivative that was not dated when it was opened.
In an interview on 08/28/19 at 2:15 PM LVN S stated the Tuberculin derivative should have been dated
when it was opened.
Observation on 08/28/19 at 02:37 PM revealed LVN T stated the Tuberculin derivative should have been
dated when it was opened.
In an interview on 08/28/19 at 3:000 PM the DON stated the Tuberculin derivative should have been dated
when it was opened and it should have been disposed of 30 days after it was opened.
Review of the website: https://www.fda.gov/media/74866/download on 08/30/2019 reflected: STORAGE
A vial of TUBERSOL (purified protein derivative) which has been entered and in use for 30 days should be
discarded. Do not use after expiration date.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675821
If continuation sheet
Page 19 of 22
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
675821
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Madisonville Care Center
411 E Collard
Madisonville, TX 77864
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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interviews and record reviews the facility failed to store, prepare, distribute and
serve food in accordance with professional standards for one (1) of one (1) kitchen.
Residents Affected - Many
The facility failed to maintain a sanitary food preparation area, sanitary serving area, and failed to label and
date food in the freezer.
This deficient practice placed residents who were served from the kitchen at risk for health complications
and foodborne illnesses.
Findings included:
Observation of the food preparation area on 8/26/2019 at 10:15 AM revealed, staff had personal drinks
where food is also served.
Observation on 8/26/2019 at 10:19 AM revealed a pan of cupcakes on a serving cart and an empty box
was touching the pan of cupcakes. The cupcakes were not covered.
Observation of a box of frozen chicken pot pies in the freezer on 8/26/2019 at 10:25 AM revealed they were
not labeled or sealed.
Observation of a bag of pepperoni slices on 8/26/2019 at 10:26 AM revealed they were not labeled and had
ice crystals formed on the meat due to it was not tightly sealed.
Observation of meal service on 8/26/2019 at 12:40 PM revealed [NAME] A touched her clothes, arm and
surfaces in dirty dish room without washing her hands or putting on gloves prior to continuing to serve food
from steam table.
Observation of meal service on 8/26/2019 at 5:23 PM revealed [NAME] B touched her clothes, touched
floor when dropped meal cover. [NAME] B didn't wash hands or use gloves when continued with meal
service from steam table.
Observation of meal service on 08/26/2019 at 5:30 PM revealed [NAME] B didn't wash her hands prior to
putting on gloves when serving the meal from the steam table.
Observation of meal service on 08/26/2019 at 5:33 PM revealed Dietary Aide C served cookies from the
cookie sheet that was tilted and the bottom edge was laying in the kitchen sink which had food particles
and stains. There was water dripping on the cookie sheet from the water faucet.
Observation of meal service on 8/26/2019 at 5:33 PM revealed Dietary Aide C served lemonade from
uncovered pitchers stored in the kitchen sink. There were food crumbs and stains in the sink.
Observation of Kitchen on 8/26/2019 at 5:40 PM revealed a box of opened, uncovered sweet potato frozen
fries (to be cooked for supper) and it had a container of packaged plastic bowls in the same box, touching
the sweet potato fries.
In an interview on 8/26/2019 at 10:15 AM the Dietary Manager stated, Staff are not to have personal
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675821
If continuation sheet
Page 20 of 22
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
675821
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Madisonville Care Center
411 E Collard
Madisonville, TX 77864
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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
drinks in the kitchen. All food is to be labeled, stored in closed containers or bags. All staff in kitchen are to
wash hands, wear gloves and change gloves as needed.
In an interview on 8/26/2019 at 5:45 PM the Dietary Manager stated, Staff uses larger scoops sometimes.
They didn't go by the portioning utensils form on the wall above the steam table when measuring food. I did
correct the staff. I explained to the cook to look at the meal slip prior to measuring food. The bowls shouldn't
be in the box with the fries. The lemonade needs to be covered and not in sink. When we serve cookies we
usually have them on food prep area.
Record Review of Facility Policy on Infection Control reflected,
2. Between handling of dirty dishes, boxes, or equipment and handling clean food or utensils.
Record Review of undated Facility Policy Storage of Food reflected, Food must be covered when stored,
with a date label identifying what is in container.
Record Review of the Texas Food Establishment Rules reflected, 228.69 (a)(2)
(d) Food Preparation. During preparation, unpackaged food shall be protected from environmental sources
of contamination.
Record review of Texas Food Establishment Rules on hand washing reflected, 228.38 (b) (4)
(c) Special Hand wash Procedures. Employees not utilizing suitable utensils or single-use gloves when
handling ready-to-eat foods shall wash hands using the cleaning procedures specified in subsection (b)(2)
of this section and follow the approved procedures specified in §228.65(a)(5) of this title.
(d) When to Wash. Food employees shall clean their hands and exposed portions of their arms as specified
under subsection (b) immediately before engaging in food preparation including working with exposed food,
clean equipment and utensils, and unwrapped single- service and single-use articles P [14] and:
(1) after touching bare human body parts other than clean hands and clean, exposed portions of arms;
(5) after handling soiled equipment or utensils; P [14]
(6) during food preparation, as often as necessary to remove soil and contamination and to prevent cross
contamination when changing tasks; P [14]
(7) when switching between working with raw food and working with ready-to-eat food; P [14]
(8) before donning gloves to initiate a task that involves working with food; P [14] and
(9) after engaging in other activities that contaminate the hands. P [14]
Record Review of Facility Infection Control Policy Equipment Sanitation revealed, All kitchenware and food
contact used in the preparation and/ or serving of food are cleaned and sanitized before use
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675821
If continuation sheet
Page 21 of 22
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
675821
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
08/28/2019
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Madisonville Care Center
411 E Collard
Madisonville, TX 77864
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)
F 0812
and cleaned after each meal preparation. Sanitizing agents are used for cleaning all surfaces.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675821
If continuation sheet
Page 22 of 22
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
9 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F602 - The resident has the right to be free from abuse, neglect, misappropriation of re
Protect each resident from the wrongful use of the resident's belongings or money.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F710 - Physician Services
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F758 - Medication Errors
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.
F761 - Labeling of Drugs and Biologicals
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.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the August 28, 2019 survey of Madisonville Care Center?
This was a inspection survey of Madisonville Care Center on August 28, 2019. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Madisonville Care Center on August 28, 2019?
Yes, 9 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from the wrongful use of the resident's belongings or money."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.