MADISON HEALTH AND REHABILITATION CENTER Nursing Home


MADISON HEALTH AND REHABILITATION CENTER (CCN: 185262) is a For profit - Limited Liability company facility located in RICHMOND, KY (40475). It is designated as a Special Focus Facility. The facility has an overall rating of /5, health inspection rating of /5, and a staffing rating of /5. It offers 92 certified beds and maintains an average of 69.8 residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 3.91322 total hours per resident per day. It has been certified since April 25, 1991 and the last listed health inspection was on November 17, 2023, The facility is located in Madison county and provides senior and nursing home care.

MADISON HEALTH AND REHABILITATION CENTER Summary


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Provider Name: MADISON HEALTH AND REHABILITATION CENTER

Address: 131 MEADOWLARK DRIVE, RICHMOND, KY 40475

Phone: (859) 623-3564

County: Madison (750)

Ownership Type: For profit - Limited Liability company

Certified Beds: 92

Average Residents Per Day: 69.8 ()

Provider Type: Medicare and Medicaid, Resides in Hospital: No

Legal Business Name: MADISON HEALTH CENTER LLC

First Approved Date: April 25, 1991

Affiliated Entity: BENJAMIN LANDA (646)

Retirement Community: N, Special Focus Status: SFF

Ownership Change in Last 12 Months: N

Resident Family Council: Resident

Sprinkler System Status: Yes

Overall Rating: (18)

Health Inspection Rating: (18)

QM Rating: (18)

Long Stay QM Rating: (18)

Short Stay QM Rating: (18)

Staffing Rating: (18)

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 2.57598, LPN Staff Hours Per Day: 0.9849, RN Staff Hours Per Day: 0.3523, Licensed Staff Hours Per Day: 1.3372

Total Nurse Staff Hours Per Day, per resident: 3.91322

Weekend Nurse Staff Hours: 3.60893, Weekend RN Staff Hours: 0.2246

PT Staff Hours Per Day, per resident: 0.0620

Nurse Staff Turnover: 82.7, Nurse Turnover Note:

RN Turnover: 100., RN Turnover Note:

Admin Left Number: 3, Admin Turnover Note:

Case Mix Nurse Aide Hours Per Day, per resident: 2.0657, Case Mix LPN Hours Per Day: 0.7908, Case Mix RN Hours Per Day: 0.3827

Adjusted Nurse Aide Hours Per Day, per resident: 2.54048, Adjusted LPN Hours Per Day: 0.9190, Adjusted RN Hours Per Day: 0.3469

Total Adjusted Nurse Hours Per Day, per resident: 3.80784

Adjusted Weekend Nurse Hours Per Day, per resident: 3.51174

Health Survey Dates and Scores: Cycle 1: 2023-11-17 (Score: 76), Cycle 2: 2023-07-01 (Score: 151), Cycle 3: 2022-03-04 (Score: 1042)

Total Weighted Health Score: 383.50

Reported Incidents: 0, Substantiated Complaints: 5

Infection Control Citations: 0

Fines and Penalties: Number of Fines: 3, Total Fines in Dollars: 323774.75, Payment Denials Number: 1, Total Penalties Number: 4

Location and GPS: 131 MEADOWLARK DRIVE,RICHMOND,KY,40475 (37.7395, -84.311)

Process Date: 2024-03-01


Health Inspection Citations Details

Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2023-07-01

Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-07-29

Citation on 2023-11-17

Type: Health, Deficiency: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-12-23

Citation on 2023-11-17

Type: Health, Deficiency: 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.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-12-23

Citation on 2023-11-17

Type: Health, Deficiency: Honor each resident's preferences, choices, values and beliefs.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-12-23

Citation on 2023-11-17

Type: Health, Deficiency: Provide activities to meet all resident's needs.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-12-23

Citation on 2023-11-17

Type: Health, Deficiency: 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.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-12-23

Citation on 2023-11-17

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-12-23

Citation on 2023-11-17

Type: Health, Deficiency: Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-12-23

Citation on 2022-03-04

Type: Health, Deficiency: Provide enough food/fluids to maintain a resident's health.

Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2023-07-01

Type: Health, Deficiency: Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-07-29

Citation on 2023-07-01

Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-07-29

Citation on 2023-07-01

Type: Health, Deficiency: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-07-29

Citation on 2023-07-01

Type: Health, Deficiency: Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-07-29

Citation on 2023-07-01

Type: Health, Deficiency: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-07-29

Citation on 2022-03-04

Type: Health, Deficiency: Ensure services provided by the nursing facility meet professional standards of quality.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-03-04

Type: Health, Deficiency: Provide safe, appropriate pain management for a resident who requires such services.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-03-04

Type: Health, Deficiency: Ensure that residents are free from significant medication errors.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-03-04

Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-03-04

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

Severity: L - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-03-04

Type: Health, Deficiency: Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-03-04

Type: Health, Deficiency: Perform COVID19 testing on residents and staff.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-03-04

Type: Health, Deficiency: Make sure that a working call system is available in each resident's bathroom and bathing area.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-03-04

Type: Health, Deficiency: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-03-04

Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-03-04

Type: Health, Deficiency: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-03-04

Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-03-04

Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-03-04

Type: Health, Deficiency: 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.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-07-05

Citation on 2022-03-04

Type: Health, Deficiency: Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Severity: L - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-03-04

Type: Health, Deficiency: Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

Severity: L - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-03-04

Type: Health, Deficiency: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-03-31

Citation on 2022-03-04

Type: Health, Deficiency: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Severity: L - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-07-05


Fire Safety Citations Details

Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2023-06-28

Type: Fire Safety, Tag: 0321, Version: New

Description: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-07-29

Citation on 2023-06-28

Type: Fire Safety, Tag: 0363, Version: New

Description: Install corridor and hallway doors that block smoke.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-07-29

Citation on 2023-06-28

Type: Fire Safety, Tag: 0372, Version: New

Description: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-07-29

Citation on 2023-06-28

Type: Fire Safety, Tag: 0374, Version: New

Description: Install smoke barrier doors that can resist smoke for at least 20 minutes.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-07-29

Citation on 2023-06-28

Type: Fire Safety, Tag: 0918, Version: New

Description: Have generator or other power source capable of supplying service within 10 seconds.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-07-29

Citation on 2023-06-28

Type: Fire Safety, Tag: 0920, Version: New

Description: Ensure proper usage of power strips and extension cords.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-07-29