Inspection Reports for Madrid Home for the Aging
613 West North Street, IA, 501561059
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 22, 2025 found the facility in substantial compliance following a complaint investigation. Earlier inspections showed a pattern of deficiencies related mainly to medication administration, care planning, and resident assessments, including issues with narcotic management and food safety. Complaint investigations included both substantiated and unsubstantiated findings, with some substantiated complaints involving medication errors and inadequate post-fall assessments. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows some improvement over time, with the latest inspection indicating compliance after prior citations.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
32% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
52 residents
Based on a August 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 22, 2025
Visit Reason
A complaint investigation was conducted for complaints #2587445-C, #2607051-C, #2608059-C, #2603083-C, #2617243-C, #2609330-C, #2624340-C, #2625294-C and #2625420-C from September 22, 2025 to September 25, 2025.
Complaint Details
Investigation of multiple complaints as listed; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Date: Aug 5, 2025
Visit Reason
The inspection was conducted as a result of investigations into complaints #129023-C, #128744-C, #129021-C, and #128291-C from July 29, 2025 to August 5, 2025.
Complaint Details
The deficiencies resulted from investigation of complaints #129023-C, #128744-C, #129021-C, and #128291-C. The report documents medication errors and narcotic management issues substantiated by clinical record review, staff interviews, and facility policy review.
Findings
The facility failed to meet professional standards of quality related to medication administration, resulting in medication errors for 2 of 2 residents reviewed. Deficiencies included missing fentanyl patches, inaccurate narcotic counts, and failure to ensure proper narcotic storage and disposal procedures.
Deficiencies (1)
Failure to assure residents received medications per physician orders resulting in medication errors for 2 of 2 residents reviewed.
Report Facts
Resident census: 52
Number of complaints investigated: 4
MDS assessment date: May 13, 2025
MDS assessment date: Jul 27, 2025
Incident report date: Apr 2, 2025
Incident report date: Apr 3, 2025
Incident report date: May 9, 2025
Medication administration frequency: 3
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 18, 2025
Visit Reason
The document serves as a Plan of Correction following a survey, indicating acceptance of credible allegation of substantial compliance and certification of the facility.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, leading to certification effective April 18, 2025.
Inspection Report
Annual Inspection
Census: 52
Deficiencies: 5
Date: Mar 20, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #125815-C, #126042-C, and #126124-C from March 17 to March 20, 2025.
Complaint Details
Complaints #126042-C and #126124-C were substantiated during the investigation.
Findings
The facility was found to have multiple deficiencies including failure to provide proper notice to residents about discontinuing Medicare Part A services, failure to meet professional standards in medication administration, inadequate assessment and care for residents with blood sugar issues, failure to properly manage psychotropic medications, and food safety violations related to storage and temperature monitoring.
Deficiencies (5)
Failed to provide notice to residents of discontinued Medicare Part A services and the right to appeal.
Failed to obtain physician and pharmacy orders for correct medication administration for 1 of 7 residents reviewed.
Failed to provide adequate assessment and intervention for resident with insulin and blood sugar issues.
Failed to ensure residents on psychotropic medications received appropriate gradual dosage reductions and documentation for PRN orders beyond 14 days.
Failed to ensure food was stored, prepared, and delivered in a manner to prevent foodborne illnesses; issues with undated dish machine test strips, improper storage of chemical jug, and incomplete temperature logs.
Report Facts
Census: 52
Deficiencies cited: 5
Dates of medication orders and reviews: Various dates including 11/7/24, 11/29/24, 3/13/25, 3/17/25, 1/6/25, 1/18/25, 2/10/25, 2/17/25, 3/31/25
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 23, 2024
Visit Reason
The visit was conducted to assess compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities based on a credible allegation of compliance and plan of correction.
Findings
The Madrid Home was found to be in substantial compliance effective June 23, 2024, based on the department's acceptance of the credible allegation of compliance and plan of correction.
Inspection Report
Annual Inspection
Census: 52
Deficiencies: 3
Date: Jun 6, 2024
Visit Reason
The inspection was conducted as the facility's annual recertification survey from June 3, 2024 to June 6, 2024.
Findings
The facility failed to meet requirements related to coordination of PASARR assessments, development and implementation of comprehensive person-centered care plans, and meeting professional standards for services provided, including proper physician orders for indwelling catheters. Multiple residents' care plans lacked focus areas, goals, and interventions to address specific diagnoses and risks such as elopement and mental health conditions.
Deficiencies (3)
Failure to coordinate PASARR assessments and refer residents with newly evident or possible serious mental disorders to the appropriate state-designated authority.
Failure to develop and implement comprehensive person-centered care plans for residents, including measurable objectives and timeframes.
Failure to meet professional standards of quality by not obtaining physician orders for indwelling catheters for residents.
Report Facts
Census: 52
Residents reviewed for care plans: 16
Residents with indwelling catheter orders missing: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding care plan updates and acknowledged deficiencies in care plans and resident elopement attempts. | |
| Assistant Director of Nursing | Interviewed regarding therapy recommendations and expectations to follow therapy recommendations. | |
| Staff A Certified Nurse Aide | Certified Nurse Aide | Interviewed and stated unawareness of right wrist brace for Resident #39. |
| Staff B | Certified Nurse Aide | Interviewed and stated Resident #39 wears a right ankle brace but no wrist brace. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 25, 2024
Visit Reason
A complaint investigation for complaint #113551-C was conducted from April 23, 2024 to April 25, 2024.
Complaint Details
Complaint #113551-C was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 8, 2023
Visit Reason
The document serves as a statement of deficiencies and plan of correction following a survey completed on May 8, 2023.
Findings
The facility was certified in compliance effective April 27, 2023, based on acceptance of a credible allegation of compliance and plan of correction.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 17, 2023
Visit Reason
The document is a plan of correction submitted following a survey to address deficiencies and certify compliance.
Findings
The facility was found to be in compliance based on acceptance of the credible allegation of compliance and plan of correction effective January 10, 2023.
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 1
Date: Dec 20, 2022
Visit Reason
The investigation was conducted due to multiple intakes and self-reports related to quality of care concerns, specifically regarding falls and neurological assessments for residents #5 and #6.
Complaint Details
Complaint #105199-C was substantiated. Complaints #107926-C and #108177-I and self-reports #108936-I were not substantiated.
Findings
The facility failed to adequately assess residents after falls, with incomplete neurological assessments and documentation. The complaint #105199-C was substantiated, while other complaints and self-reports were not substantiated.
Deficiencies (1)
Failure to assure residents were adequately assessed after a fall for 2 of 3 residents reviewed (Residents #5 and #6), including lack of neurological status documentation per facility protocol.
Report Facts
Census: 48
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Adam Johnston | Laboratory Director or Provider/Supplier Representative | Signed the Plan of Correction document |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 5
Date: Nov 22, 2021
Visit Reason
A recertification health survey and investigation of Complaint #100487 was completed on 11-22-21 to assess compliance with federal and state regulations.
Complaint Details
Complaint #100487 was investigated and found to be not substantiated.
Findings
The facility was found not to have completed required criminal/abuse background checks and dependent adult abuse training for newly hired staff. The facility also failed to provide bed-hold notices to residents or their representatives upon hospital transfer, did not consistently develop baseline care plans within 48 hours of admission, failed to keep medications secured, and did not maintain proper infection control practices including eye protection and COVID-19 testing protocols.
Deficiencies (5)
Facility failed to complete criminal/abuse background check and dependent adult abuse training for newly hired staff.
Facility failed to provide resident/resident representative notice of bed hold policy at time of hospital transfer for two residents.
Facility failed to develop and implement baseline care plan within 48 hours for residents.
Facility failed to keep medications secured in locked medication cart.
Facility failed to maintain infection control practices including eye protection for staff and proper COVID-19 testing and outbreak procedures.
Report Facts
Facility census: 56
Facility census: 63
Residents reviewed: 14
Residents reviewed: 3
Residents reviewed: 2
Residents reviewed: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in deficiency related to background check and dependent adult abuse training | |
| Staff A | Registered Nurse | Named in medication cart security deficiency |
| Director of Nursing | Director of Nursing | Provided statements regarding care plan and medication cart deficiencies |
| Administrator | Administrator | Provided statements regarding bed hold policy and infection control deficiencies |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 3
Date: Jan 25, 2021
Visit Reason
A focused COVID-19 infection control survey and investigation of Complaints #86610-C, #87023-C, and #94044-C was conducted ending 1/25/21.
Complaint Details
Complaint #86610-C was substantiated. Complaint #87023-C was not substantiated. Complaint #94044-C was substantiated.
Findings
The facility was found not in compliance with CMS and CDC recommended practices to prepare for COVID-19. Deficiencies were identified related to incontinence care, catheter care, medication administration and destruction, infection prevention and control, and hand hygiene practices. Some complaints were substantiated while one was not.
Deficiencies (3)
Failure to provide complete incontinence care for residents requiring assistance, including proper catheter care and changing gloves when soiled.
Failure to ensure narcotics and controlled substances were destroyed with two staff witnesses and proper documentation.
Failure to ensure infection prevention and control practices, including changing gloves when soiled and sanitizing hands to prevent spread of infection.
Report Facts
Census: 56
Deficiencies cited: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant (CNA) | Observed providing incontinence care and assisting residents |
| Staff D | Certified Nursing Assistant (CNA) | Observed providing incontinence care and assisting residents |
| Staff C | Certified Nursing Assistant (CNA) | Observed providing catheter care and incontinence care |
| Staff E | Registered Nurse (RN) | Reported medication wastage and destruction |
| Staff F | Certified Medication Aide (CMA) | Reported medication wastage and destruction |
| Staff G | Reported staff documented amount of controlled medication wasted | |
| Staff H | Certified Medication Aide (CMA) | Reported medication wastage and destruction |
| Staff I | Licensed Practical Nurse (LPN) | Reported medication wastage |
| Staff J | Certified Medication Aide (CMA) | Reported medication wastage and destruction |
| Assistant Director of Nursing | Reported expectations for staff to change gloves and cleanse catheter tubing | |
| Director of Nursing | Reported staff wasted unused narcotics |
Inspection Report
Abbreviated Survey
Census: 75
Deficiencies: 0
Date: Jul 13, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total residents: 75
Inspection Report
Routine
Census: 76
Deficiencies: 0
Date: Jun 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Report
Mar 20, 2025
Report
Mar 20, 2025
Report
Jun 6, 2024
Report
May 8, 2023
Report
Mar 27, 2023
Report
Mar 27, 2023
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