Madison Post Acute: Care Plan Safety Failures - WA
The resident told inspectors at Madison Post Acute in July that they used their cane to pull the blue foam wedge from the foot of their bed and position it under their right hip. There was no strap attached, despite the care plan requiring one for safety. The resident said they hadn't used the wedge the night before and needed no reminders from staff.
Federal inspectors who visited the facility in August found the wedge wasn't being monitored or properly secured, violating the resident's care plan that was updated after their January fall. The therapy assessment had specifically recommended the wedge be "secured with a strap that is attached to the bed frame" due to the resident's poor trunk control.
When inspectors interviewed a nursing assistant about the wedge, the aide initially said it was for the resident's wound and comfort. The aide didn't know about the strap requirement and said the resident wasn't using their wedge when last checked.
The Director of Nursing Services said she wasn't aware the resident didn't want to use the strap.
Madison Post Acute failed to implement care plans for multiple residents during the August 7, 2024 inspection, including two residents whose care needs had changed but whose plans weren't updated to reflect their current conditions.
One resident's partial dentures had been sent to a dentist before the COVID pandemic and never returned, yet the care plan still indicated they wore an upper partial and required staff assistance with oral care. The resident told inspectors they were having difficulty chewing meat without their dentures.
Two nursing staff members told inspectors the resident was wearing their partial when they checked on them. But when inspectors observed the resident's mouth, no upper partials were in place.
A Licensed Practical Nurse confirmed the resident didn't have their partials but was scheduled to see a dentist in September to get fitted for new ones. The care plan had not been updated to reflect the resident's actual condition.
Another resident's discharge plan hadn't been revised despite significant changes to their housing situation. The resident had planned to move to an assisted living facility next door but became "over resourced" and couldn't afford the move. The Social Services Director said she had been emailing weekly with a case worker about the situation since July 17, but the care plan still showed the resident would discharge home with assisted living as a backup option.
The facility also failed to follow professional standards for medication monitoring and swallowing safety. One diabetic resident with high blood pressure was prescribed medication that required blood pressure checks before each dose, but staff weren't taking the measurements.
The resident's medication record showed an order to hold the blood pressure medication if their systolic pressure dropped below 100, but no blood pressures were documented from August 1 through August 5. The Director of Nursing Services said a blood pressure monitor had been "somehow left off" when medication times were changed.
The same resident had lab work ordered on July 18 that wasn't completed until August 2 — 15 days late. The facility consultant blamed the delay on difficulties with their new electronic medical record system.
A stroke patient who required specialized swallowing techniques during their one daily meal wasn't receiving proper supervision. The resident had a feeding tube for nutrition but was allowed one recreational meal Monday through Friday with specific safety strategies recommended by speech therapy.
Inspectors observed staff failing to cue the resident to tuck their chin or swallow hard as recommended. The resident coughed during the meal, but staff only asked if they were okay without providing the required verbal prompts. The swallowing safety strategies weren't included in the resident's care plan or the nursing assistant's care directives.
Basic hygiene care was severely lacking for two residents who depended on staff assistance. One resident was observed with visible brown matter under all their fingernails, an oily scalp with dried skin debris in their hair, and teeth covered in film with white debris built up between them.
During a continuous observation lasting nearly two hours, the resident received no assistance with their untouched meal tray and no hygiene care. The resident later told inspectors they hadn't had their teeth brushed in two days. Multiple cups of liquid sat on their bedside table, including what appeared to be spoiled beverages that had been sitting out for unknown periods.
Another resident who received nutrition through a feeding tube had dry, flaky lips and a tongue coated in white matter. The resident said staff rarely helped them swab their mouth, which was always dry. Their care plan called for glycerin swabs to stimulate saliva, but there was no documentation this care was being provided.
The facility's infection control practices also drew citations. Staff weren't properly using personal protective equipment when entering a COVID-positive resident's room. One nursing assistant entered wearing only an N95 mask instead of the required gown, gloves, and eye protection. The aide said they weren't aware the resident was on isolation precautions.
Another staff member wore a surgical mask instead of an N95 when entering the same room and improperly removed their protective equipment by rolling up the gown and throwing it away down the hallway instead of at the room's entrance.
Clean oxygen tubing for a sleep apnea patient was stored improperly on top of the concentrator machine rather than in a protective bag. The tubing was also found lying on the floor during one inspection visit. A registered nurse acknowledged it wasn't good practice to store the tubing on top of the equipment.
Food safety violations included expired ketchup, unlabeled food items, and uncovered desserts during meal delivery. Kitchen staff failed to maintain proper dishwasher temperatures and left temperature monitoring logs incomplete. A nourishment refrigerator contained expired items and unlabeled food that remained there for multiple days despite daily checks by dietary staff.
The facility also failed to complete required annual performance evaluations for nursing assistants and didn't provide adequate continuing education. One aide had only 6.3 hours of training instead of the required 12 hours annually.
Six resident rooms measured below the required square footage, with some double-occupancy rooms providing only 71 square feet per resident instead of the mandated 80 square feet.
Many of these violations were repeat citations from the facility's previous inspection in October 2023.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Madison Post Acute from 2024-08-07 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
MADISON POST ACUTE in EVERETT, WA was cited for violations during a health inspection on August 7, 2024.
There was no strap attached, despite the care plan requiring one for safety.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.