THE MADISON HEALTH AND REHAB Nursing Home


THE MADISON HEALTH AND REHAB (CCN: 255276) is a For profit - Limited Liability company facility located in MADISON, MS (39110). The facility has an overall rating of 1/5, health inspection rating of 2/5, and a staffing rating of 3/5. It offers 60 certified beds and maintains an average of 55.4 residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 4.70008 total hours per resident per day. It has been certified since July 1, 2001 and the last listed health inspection was on September 21, 2023, The facility is located in Madison county and provides senior and nursing home care.

THE MADISON HEALTH AND REHAB Summary


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Provider Name: THE MADISON HEALTH AND REHAB

Address: 111 KELLY BLVD, MADISON, MS 39110

Phone: (601) 355-0763

County: Madison (440)

Ownership Type: For profit - Limited Liability company

Certified Beds: 60

Average Residents Per Day: 55.4 ()

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

Legal Business Name: BELHAVEN SENIOR CARE LLC

First Approved Date: July 1, 2001

Affiliated Entity: TREND CONSULTANTS (522)

Retirement Community: N, Special Focus Status:

Ownership Change in Last 12 Months: N

Resident Family Council: Resident

Sprinkler System Status: Yes

Overall Rating: 1 ()

Health Inspection Rating: 2 ()

QM Rating: 1 ()

Long Stay QM Rating: 1 ()

Short Stay QM Rating: 3 ()

Staffing Rating: 3 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 2.38700, LPN Staff Hours Per Day: 1.6727, RN Staff Hours Per Day: 0.6403, Licensed Staff Hours Per Day: 2.3130

Total Nurse Staff Hours Per Day, per resident: 4.70008

Weekend Nurse Staff Hours: 3.44195, Weekend RN Staff Hours: 0.2659

PT Staff Hours Per Day, per resident: 0.1196

Nurse Staff Turnover: 69.5, Nurse Turnover Note:

RN Turnover: 70.0, RN Turnover Note:

Admin Left Number: 1, Admin Turnover Note:

Case Mix Nurse Aide Hours Per Day, per resident: 1.9864, Case Mix LPN Hours Per Day: 0.7435, Case Mix RN Hours Per Day: 0.3946

Adjusted Nurse Aide Hours Per Day, per resident: 2.44804, Adjusted LPN Hours Per Day: 1.6602, Adjusted RN Hours Per Day: 0.6113

Total Adjusted Nurse Hours Per Day, per resident: 4.74127

Adjusted Weekend Nurse Hours Per Day, per resident: 3.47211

Health Survey Dates and Scores: Cycle 1: 2023-09-21 (Score: 8), Cycle 2: 2022-04-07 (Score: 88), Cycle 3: 2019-09-26 (Score: 80)

Total Weighted Health Score: 46.667

Reported Incidents: 0, Substantiated Complaints: 2

Infection Control Citations: 0

Fines and Penalties: Number of Fines: 1, Total Fines in Dollars: 9087.00, Payment Denials Number: 0, Total Penalties Number: 1

Location and GPS: 111 KELLY BLVD,MADISON,MS,39110 (32.4679, -90.122)

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 2023-09-21

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

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 2023-10-31

Citation on 2022-04-07

Type: Health, Deficiency: PASARR screening for Mental disorders or Intellectual Disabilities

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 2022-05-31

Citation on 2022-04-07

Type: Health, Deficiency: Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.

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 2022-05-31

Citation on 2022-04-07

Type: Health, Deficiency: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

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 2022-05-31

Citation on 2022-04-07

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

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 2022-05-31

Citation on 2022-04-07

Type: Health, Deficiency: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

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 2022-05-31

Citation on 2022-04-07

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 2022-05-31

Citation on 2022-04-07

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

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 2022-05-31

Citation on 2022-04-07

Type: Health, Deficiency: Ensure staff are vaccinated for COVID-19

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 2022-05-31

Citation on 2022-04-07

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

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 2022-05-31

Citation on 2022-04-07

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 2022-05-31

Citation on 2022-04-07

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: 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 2022-05-31

Citation on 2022-04-07

Type: Health, Deficiency: Provide care and assistance to perform activities of daily living for any resident who is unable.

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 2022-05-31

Citation on 2019-09-26

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

Corrected: Deficient, Provider has date of correction on 2019-10-25

Citation on 2019-09-26

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 2019-10-25

Citation on 2019-09-26

Type: Health, Deficiency: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

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 2019-10-25

Citation on 2019-09-26

Type: Health, Deficiency: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

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 2019-10-25

Citation on 2019-09-26

Type: Health, Deficiency: 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.

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 2019-10-25

Citation on 2019-09-26

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: 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 2019-10-25

Citation on 2019-09-26

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 2019-10-25

Citation on 2019-09-26

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 2019-10-25


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 2022-04-08

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 2022-04-08