MADISON HOUSE

An administrative relicensure survey was completed on 2/25/26. No deficiencies were cited.

A revisit survey was completed on 4/26/24 for all previous deficiencies cited on 1/24/24. The facility is in compliance with all deficiencies that were cited.

A relicensure survey was completed on 1/24/24. No deficiencies were cited.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.7.13 Each personnel file shall include, but not be limited to, written documentation regarding the following items:(C) Orientation and training. 13.4 The house rules shall list all possible actions which may be taken by the assisted living residence if any rule is knowingly violated by a resident. House rules shall not supersede or contradict any regulation herein, or in any way discourage or hinder a resident's exercise of his or her rights. House rules shall address, at a minimum, the following items:(A) Smoking, including the use of electronic cigarettes and vaporizers(G) Consumption of alcohol and marijuana. 14.31 The administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. The results of the audits shall be documented and routinely included as part of the assisted living residence's Quality Management Program assessment and review.

A recertification survey was completed on 1/24/24. A deficiency was cited.

Based on observation, record review, and interview, the facility (residence) failed to ensure that participants (residents) had access to food at all times and had the choice of when and what to eat, affecting 23 current residents. Findings include:1. Residence Policya. The residence's resident agreement, dated January 2023, read in part that the residence provided three meals daily and access to food at all times.b. The residence's Independent Access to Food policy, dated March 2022, read in part that the residence provided residents with the ability to access food and beverages independently, and at all hours of the day and night. Independent access was the ability for the resident to acquire food and drinks on their own, without the necessity of asking a staff member for permission or assistance. 2. ObservationThroughout the onsite visit on 1/24/24 from 7:30 a.m. to 1:00 p.m., the residence did not provide residents with independent access to food. 3. Record ReviewProgress notes dated 12/12/23 to 1/21/24 read as follows:12/12/23 at 9:39 p.m.: At approximately 10:00 p.m., Resident #1 came to the dining room asking for a snack. Staff assisted her with some crackers. 12/20/23 at 2:14 p.m.: Resident #1 did not come to breakfast when staff went to get her at 8:30 a.m. The resident wanted breakfast at 9:30 a.m. Staff told the resident it was too late for breakfast, adding that the resident was required to come to the dining room before 9:00 a.m. if she wanted to eat. Resident #1 returned to her room until lunch time. 12/31/23 at 9:40 p.m.: Resident #1 "came to supper in the dining room late (5:30 p.m.). The cook informed her that supper was at 5:00 p.m. and she would have to wait until the morning ... Resident (#1) came down later to (the) dining room. Staff offered to warm up leftovers from lunch if (the) resident wanted something to eat. Resident (#1) refused and voiced she only wanted water then returned to (her) room."1/4/24 at 10:23 p.m.: Resident #1 came to the dining room at 9:30 p.m. to get a glass of water. She took a couple jelly packs to her room. Staff asked her if she wanted a snack, but she said "no" and went back to her room. 1/21/24 at 9:23 p.m.: Resident #1 came to the dining room to request ice cream from the kitchen. Staff asked the resident if she had her own ice cream, to which she answered "no." Staff reminded Resident #1 that the food in the kitchen belonged to other residents. Staff asked Resident #1 if she would like a cookie or crackers. Resident #1 stated, "No. I'll just drink a glass of water and head back to my room."4. InterviewsOn 1/24/24 at 10:23 a.m., Resident #4 acknowledged that the residence did not provide independent access to snacks. She stated she once asked a kitchen staff member for buttered toast, and they did not provide it. She stated that she subsequently stopped asking staff for food when she was hungry. On 1/24/24 at 10:34 a.m., the activity coordinator stated the residence had not had an area for residents to independently access food since she started working at the residence (in September 2023). She added that if residents wanted a snack, they had to ask staff for one. On 1/24/24 at 11:04 a.m., the resident services coordinator stated the residence had set out snacks like trail mix and fruit in the past, but they stopped doing so because staff frequently had to dispose of the food items when residents did not eat them. She stated that residents were required to ask staff when they wanted snacks. On 1/24/24 at 12:01 p.m., Resident #1 stated she was required to ask for food when she wanted it. On 1/24/24 at 12:47 p.m., the administrator stated that staff offered snacks to residents at 10:00 a.m. and 3:00 p.m. unless the residents asked staff for one. She acknowledged that the residence had no food available for residents to independently access during the onsite visit.