MADISON MEDICAL CENTER

Nursing Home Inspector

611 WEST MAIN STREET, PO BOX 431
FREDERICKTOWN, MO 63645
Madison County
Phone: 573-783-3341
Provider Number: 265561
Last Inspection: 04/28/2017

About the Nursing Home

Number of Beds: 119
Number of Residents: 76
Beds Available: 43
Percent Occupancy: 64%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Both
Ownership: Government - City/county
Within Hospital?: YES

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

11

Facility
8

County
21

MO
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

11

2017
17

2016
11

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

4/28/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 6/2/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 6/2/2017
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Isolated : Minimal 3 6/2/2017
 

3/10/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 4/28/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 4/28/2016
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated : Minimal 3 4/28/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 4/28/2016
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Isolated : Minimal 3 4/28/2016
 

6/5/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 7/8/2015
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 7/8/2015
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Isolated : Minimal 3 7/8/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

No Complaint Deficiencies Reported

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MO State Avg
Number of Residents 76 76.50 74.26
Registered Nurses 0.94 0.71 0.60
Licensed Practical / Vocational Nurses 0.51 0.48 0.72
Certified Nursing Assistants 2.63 2.43 2.43
Total Staff Hours 4.08 3.62 3.75

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MO State Avg%
of high risk long-stay residents with pressure ulcers 5 3 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 96 85 88
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 99 96 93
of long-stay residents experiencing one or more falls with major injury 2 2 4
of long-stay residents who have depressive symptoms 0 0 3
of long-stay residents who lose too much weight 10 10 7
of long-stay residents who received an antianxiety or hypnotic medication 21 26 26
of long-stay residents who received an antipsychotic medication 9 18 18
of long-stay residents who self-report moderate to severe pain 4 10 7
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 8 9 15
of long-stay residents whose need for help with daily activities has increased 11 9 14
of long-stay residents with a catheter inserted and left in their bladder 2 1 2
of long-stay residents with a urinary tract infection 4 3 4
of low risk long-stay residents who lose control of their bowels or bladder 30 24 32
of short-stay residents assessed and appropriately given the pneumococcal vaccine 46 49 74
of short-stay residents who newly received an antipsychotic medication 0 21 12
of short-stay residents who self-report moderate to severe pain 10 Not Available   68
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 88 2 2
of short-stay residents with pressure ulcers that are new or worsened 0 22 16