Inspection Reports for The Bay at Belmont Health and Rehabilitation Center
WI, 53714
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
35.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
676% worse than Wisconsin average
Wisconsin average: 4.6 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
24 residents
Based on a March 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Deficiencies: 3
Dec 15, 2025
Visit Reason
The inspection was conducted based on complaints and observations regarding residents' rights to dignified existence and self-determination, safe and clean environment, and proper reporting of alleged violations.
Findings
The facility failed to ensure a resident's preference for staff to wear masks was respected, did not maintain a clean commode for a resident, and failed to report investigation results of an alleged misappropriation of property within the required timeframe.
Complaint Details
The complaint investigation involved a resident (R4) whose preference for staff to wear masks was not consistently respected, a resident (R2) whose commode was found unclean with stool residue, and a facility reported incident involving alleged misappropriation of property where investigation results were reported late.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to honor a resident's right to a dignified existence, self-determination, and communication, specifically staff not wearing masks as requested by the resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure a safe, clean, comfortable and homelike environment, evidenced by a commode with a brown substance on the seat and arm. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to report results of investigations of alleged violations to the resident or designated representative and to other officials within 5 working days as required. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 6
Residents affected: 1
Residents affected: 1
Residents affected: 1
BIMS score: 14
BIMS score: 0
Missing money amount: 160
Working days late: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Interviewed regarding residents' preferences, mask policy, commode cleaning, and reporting procedures |
| CNA D | Certified Nursing Assistant | Observed entering resident R4's room without mask |
| CNA E | Certified Nursing Assistant | Interviewed about mask sign and staff compliance |
| LPN C | Licensed Practical Nurse | Interviewed regarding unclean commode in resident R2's room |
| UM F | Unit Manager | Indicated adding mask preference to care plan |
| NHA A | Nursing Home Administrator | Interviewed about reporting timelines for investigations |
Inspection Report
Annual Inspection
Deficiencies: 7
Aug 26, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home operations, including medication administration, resident rights, safety, dietary services, and infection control.
Findings
The facility was found deficient in multiple areas including improper self-administration of medications without proper assessment and orders, failure to document resident advance directives, inadequate supervision and safety measures for residents at risk of falls and smoking, medication administration errors related to insulin pen use, failure to accommodate resident food allergies and intolerances, poor food service safety and sanitation practices, and lapses in infection prevention and control practices including improper PPE use and hand hygiene.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Allow residents to self-administer drugs without proper clinical assessment and active physician orders. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure every resident had an advance directive including code status documented. | Level of Harm - Minimal harm or potential for actual harm |
| Inadequate supervision and safety to prevent accidents for residents at risk of falls and smoking. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to prime insulin pen prior to administration resulting in medication error. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to accommodate resident allergies and intolerances in food service; residents served foods containing allergens and milk alternatives not provided. | Level of Harm - Minimal harm or potential for actual harm |
| Food service safety violations including improper food storage, lack of labeling and dating, poor kitchen cleanliness, staff not wearing beard restraints, and improper food handling. | Level of Harm - Minimal harm or potential for actual harm |
| Infection prevention and control program deficiencies including improper PPE use and failure to perform hand hygiene between glove changes. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Number of residents sampled: 2
Number of residents cited: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 72
Residents affected: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN V | Registered Nurse | Named in insulin pen medication error and infection control hand hygiene deficiency |
| LPN H | Licensed Practical Nurse | Interviewed regarding medication self-administration deficiency |
| DON B | Director of Nursing | Interviewed regarding multiple deficiencies including medication self-administration, advance directives, smoking evaluation, insulin pen use, dietary issues, and infection control |
| NHA A | Nursing Home Administrator | Interviewed regarding dietary and infection control deficiencies |
| DM C | Dietary Manager | Interviewed regarding food allergy accommodation and food service safety deficiencies |
| CNA E | Certified Nursing Assistant | Named in food allergy meal delivery deficiency |
Inspection Report
Routine
Census: 24
Deficiencies: 10
Mar 25, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey of Madison Health and Rehabilitation Center to assess compliance with healthcare facility regulations, including resident care, environment, and safety.
Findings
The facility was found deficient in multiple areas including failure to notify physicians of changes in resident condition, inadequate cleanliness and maintenance of resident environment and shower rooms, failure to promptly and properly address resident grievances, inaccurate resident assessments, failure to provide scheduled personal care, inadequate wound care and monitoring, failure to monitor resident weight and fluid status per physician orders, unsafe use and assessment of bed rails/enabler bars, and improper catheter care leading to potential resident harm.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Level of Harm - Actual harm: 2
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to immediately notify and consult with the resident's physician when a change in condition occurred for 1 of 24 residents (R71). | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure a safe, clean, comfortable and homelike environment for daily living for 1 of 24 sampled residents (R51), 2 supplemental residents, and 5 of 6 shower rooms. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to make prompt efforts to document, investigate, and resolve grievances for 1 of 8 residents (R73). | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure accurate resident assessments for 2 of 20 residents (R17 and R8). | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide scheduled personal care and assistance with activities of daily living for 1 of 20 residents (R51). | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate wound care treatment according to physician orders for 1 of 20 residents (R37). | Level of Harm - Actual harm |
| Failure to monitor, record, and report weight and fluid status per physician orders for 1 of 20 residents (R41), resulting in significant weight loss and hospitalization. | Level of Harm - Actual harm |
| Failure to provide appropriate care for residents with indwelling catheters to prevent urinary tract infections for 1 of 2 residents (R65) as catheter bags were observed uncovered and resting on the floor. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure a resident's environment remained free of accident hazards for 1 of 7 residents (R61) due to broken bed, bed not in lowest position, missing fall mats, and call light not in reach. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to try alternatives prior to using bed rails, failure to assess risk of entrapment, failure to obtain informed consent, and failure to properly maintain bed rails for multiple residents, creating immediate jeopardy that was removed but remains a pattern. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Residents reviewed: 24
Residents reviewed for grievances: 8
Residents reviewed for ADLs: 20
Residents reviewed for wound care: 20
Residents reviewed for bed rails: 21
Weight loss: 13.2
Weight gain: 4
Weight loss: 6.9
Weight gain: 5.8
Weight loss: 9
Weight loss: 13.2
Weight gain: 5
Weight gain: 3
Weight loss: 5
Residents with side rails: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Interviewed regarding notification of physician, cleanliness, grievance handling, weight monitoring, bed rails, catheter care, and immediate jeopardy |
| NHA A | Nursing Home Administrator | Interviewed regarding grievance handling, bed rails, and immediate jeopardy |
| LPN MM | Licensed Practical Nurse | Interviewed regarding cleanliness of resident room |
| Hskp NN | Housekeeper | Interviewed regarding cleaning procedures |
| Hskp Spv OO | Housekeeping Supervisor | Interviewed regarding cleaning procedures |
| CNA S | Certified Nursing Assistant | Interviewed regarding shower room conditions and catheter bag placement |
| CNA G | Certified Nursing Assistant | Interviewed regarding catheter bag placement |
| SW H | Social Worker | Interviewed regarding grievance investigations and follow-up |
| SSA X | Social Services Assistant | Interviewed regarding grievance investigations |
| MDS Coordinator I | Interviewed regarding resident assessments | |
| NP J | Palliative Care Nurse Practitioner | Interviewed regarding wound care |
| IP D | Infection Preventionist/Wound Nurse | Interviewed regarding wound care and treatment orders |
| LPN JJ | Licensed Practical Nurse | Interviewed regarding side rail assessments |
| PTA R | Physical Therapy Assistant | Interviewed regarding side rail assessments and resident mobility |
| MD Q | Maintenance Director | Interviewed regarding bed maintenance and side rail assessments |
| LPN WW | Licensed Practical Nurse | Interviewed regarding side rails and assessments |
| RN XX | Registered Nurse | Interviewed regarding side rails and assessments |
Inspection Report
Deficiencies: 20
Mar 25, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including medication self-administration assessments, failure to notify physicians of changes in condition, unsafe and unclean environment, inadequate grievance resolution, inaccurate resident assessments, failure to provide necessary personal care, lack of culturally competent communication, failure to monitor residents' weight and vital signs, improper pressure injury prevention and treatment, unsafe use of bed rails, inadequate infection prevention and control practices, and failure to ensure timely physician visits and documentation.
Severity Breakdown
Immediate jeopardy: 2
Actual harm: 2
: 16
Deficiencies (20)
| Description | Severity |
|---|---|
| The facility did not ensure that all residents are clinically appropriate to self-administer medications and lacked assessments for self-administration. | — |
| The facility failed to immediately notify and consult with the resident's physician when a change in condition occurred. | — |
| The facility did not ensure a safe, clean, comfortable, and homelike environment for residents, including unclean shower rooms and resident rooms. | — |
| The facility did not make prompt efforts to document, investigate, and resolve resident grievances. | — |
| The facility failed to ensure accurate resident assessments, including errors in Minimum Data Set (MDS) documentation. | — |
| The facility did not ensure residents received necessary assistance with activities of daily living, including scheduled showers. | — |
| The facility did not provide an ongoing program of activities designed to meet the interests and well-being of residents, including lack of culturally appropriate activities and communication. | — |
| The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and professional standards, including failure to monitor weight changes and follow wound care orders. | — |
| The facility failed to prevent pressure ulcers and provide appropriate treatment, including failure to identify, assess, and treat pressure injuries in a timely manner. | Immediate jeopardy |
| The facility did not ensure residents with indwelling catheters received appropriate care to prevent urinary tract infections, including catheter bags resting on the floor. | — |
| The facility failed to provide safe and appropriate dialysis care and services, including lack of monitoring and staff knowledge of emergency procedures. | — |
| The facility failed to ensure proper assessment, consent, and safe use of bed rails and enabler bars, increasing risk for entrapment. | Immediate jeopardy |
| The facility failed to ensure effective communication and cultural competency for residents with limited English proficiency, including lack of interpreter use and culturally appropriate activities. | — |
| The facility failed to ensure timely physician visits and signing of physician orders for multiple residents. | — |
| The facility failed to complete annual performance evaluations for multiple Certified Nursing Assistants (CNAs). | — |
| The facility did not store, prepare, distribute, and serve food in accordance with professional standards, including lack of thaw dates on nutritional supplements and failure to report dishwasher sanitizing issues. | — |
| The facility did not dispose of garbage and refuse properly, with garbage and litter found near the main dumpster area. | — |
| The facility did not conduct and document a comprehensive facility-wide assessment that included all necessary resources, staff competencies, and cultural needs to care for residents competently. | — |
| The facility failed to implement an infection prevention and control program consistent with accepted standards, including failure to control an outbreak of multi-drug resistant organisms (MDROs), inadequate hand hygiene, improper handling of soiled linens, and lack of annual policy review. | Actual harm |
| The facility failed to implement an antibiotic stewardship program consistent with policy, including inappropriate antibiotic use and lack of monitoring and education. | — |
Report Facts
Weight loss: 13.2
Weight gain: 5.8
Braden score: 11
Pressure injury size: 3.3
Pressure injury size: 2.8
Pressure injury size: 0.1
ESBL cases: 4
Dishwasher PPM: 10
Mighty Shakes thawed: 7
CNA annual evaluations missing: 4
Residents with side rails: 11
Residents with missing signed physician orders: 9
Residents with missed provider visits: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Interviewed regarding multiple findings including medication self-administration, weight monitoring, infection control, and side rails |
| RN F | Registered Nurse | Interviewed and observed during medication administration and wound care |
| LPN E | Licensed Practical Nurse | Interviewed regarding medication administration and self-administration assessments |
| LPN AA | Licensed Practical Nurse | Interviewed regarding wound care and infection control |
| IP D | Infection Preventionist | Interviewed regarding infection control program and outbreak management |
| NHA A | Nursing Home Administrator | Interviewed regarding facility assessments and side rails |
| NP C | Nurse Practitioner | Interviewed regarding wound care and infection control |
| CNA G | Certified Nursing Assistant | Interviewed regarding wound care and catheter care |
| CNA M | Certified Nursing Assistant | Observed and interviewed regarding communication and infection control |
| SW H | Social Worker | Interviewed regarding grievance process and activities |
| PTA R | Physical Therapy Assistant | Interviewed regarding side rail assessments and resident mobility |
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 13, 2024
Visit Reason
The inspection was conducted due to concerns about inadequate supervision, monitoring, and evaluation of residents after falls, specifically for two sampled residents (R2 and R3).
Findings
The facility failed to document post-fall clinical findings or evaluate the effectiveness of fall interventions for residents R2 and R3 after their falls. The Director of Nursing was unable to provide post-fall monitoring documentation for these residents as required by facility policy and clinical guidelines.
Complaint Details
The complaint investigation found that the facility did not document relevant post-fall clinical findings or new fall intervention effectiveness for residents R2 and R3 after their unwitnessed falls. The facility policy requires monitoring and documentation for at least 72 hours post-fall, which was not provided. The Director of Nursing confirmed the expectation for such documentation but was unable to provide it.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure adequate supervision, monitoring, and evaluation for 2 of 4 sampled residents after falls, including lack of documentation of post-fall clinical findings and intervention effectiveness. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents sampled: 4
Residents affected: 2
Fall date and time for R2: 11/1/24 at 1:00 PM
Fall date and time for R3: 10/28/24 at 4:55 PM
BIMS score for R2: 12
BIMS score for R3: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Interviewed regarding fall policy and post-fall monitoring; unable to provide documentation for R2 and R3 |
| LPN C | Licensed Practical Nurse | Interviewed regarding post-fall procedure and documentation requirements |
| LPN D | Licensed Practical Nurse | Interviewed regarding post-fall procedure and documentation requirements |
Inspection Report
Routine
Deficiencies: 21
Oct 10, 2024
Visit Reason
The inspection was a routine survey of Madison Health and Rehabilitation Center to assess compliance with regulatory requirements including resident rights, safety, care planning, medication administration, infection control, and other aspects of care.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to dignity and privacy, unsafe and unsanitary environment, failure to follow grievance procedures, delayed reporting and incomplete investigation of abuse allegations, lack of timely notification to ombudsman for transfers, incomplete PASARR screenings, incomplete and inaccurate care plans, failure to provide scheduled showers, medication errors and delays, inadequate infection control practices, and failure to provide appropriate supervision for residents at risk of elopement.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 21
Deficiencies (21)
| Description | Severity |
|---|---|
| Failure to honor resident's right to be treated with respect and dignity, including privacy during care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure a safe, clean, comfortable, and homelike environment, including proper handling of soiled linen and spills. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to follow grievance policy and make prompt efforts to resolve grievances for residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report suspected abuse and incomplete investigation of abuse allegations. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to notify the State Long-Term Care Ombudsman of resident transfers/discharges. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide required written bed-hold notice to residents transferred to hospital. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to complete PASARR Level II screening for residents residing longer than 30 days. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop comprehensive, person-centered care plans including discharge planning and accurate resident information. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents or their representatives participate in care planning process. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide services consistent with person-centered care plans, including failure to follow physician orders for sleep assessment and ketoconazole shampoo application. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide adequate supervision and assistance devices to prevent accidents, including failure to maintain code alert bracelets for residents at risk of elopement and leaving medication cart unlocked. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate diabetic foot care consistent with professional standards. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate treatment and services for residents with mental disorders or history of trauma, including lack of individualized trauma-informed care plans. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide pharmaceutical services to meet residents' needs, including late administration of medications and missed insulin doses. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide safe and appropriate respiratory care, including failure to change oxygen tubing weekly. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to procure food from approved sources and store, prepare, distribute and serve food in a clean and sanitary environment. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate care for residents who are continent or incontinent of bowel/bladder, including improper catheter care and hand hygiene. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide safe and appropriate respiratory care for a resident when needed, including lack of proper respiratory and cardiac assessments during change in condition. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate foot care for diabetic residents consistent with professional standards. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure residents are free from significant medication errors, including late administration and missed doses. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide and implement an infection prevention and control program, including failure to follow transmission-based precautions and hand hygiene. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 20
Residents affected: 64
Residents affected: 5
Residents affected: 21
Residents affected: 7
Residents affected: 3
Residents affected: 4
Residents affected: 2
Residents affected: 3
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| SCH C | Scheduler | Named in privacy and dignity violation for being in resident room without CNA license |
| DON B | Director of Nursing | Interviewed regarding multiple deficiencies including privacy violation, grievance process, abuse investigation, medication administration, infection control |
| NHA A | Nursing Home Administrator | Interviewed regarding abuse investigation, grievance process, care planning, medication administration, elopement risk |
| LPN E | Licensed Practical Nurse | Unit manager involved in abuse investigation and care planning |
| RN F | Registered Nurse | Involved in abuse investigation and medication administration |
| CNA K | Certified Nursing Assistant | Interviewed regarding shower assistance and refusal documentation |
| SW D | Social Worker | Interviewed regarding grievance process, PASARR screening, care planning, trauma informed care |
| LPN HH | Licensed Practical Nurse | Failed to replace code alert bracelet for resident at risk of elopement |
| RN W | Registered Nurse | Failed to replace code alert bracelet and involved in medication administration observation |
| LPN DD | Licensed Practical Nurse | Unaware of code alert bracelet purpose for elopement risk residents |
| LPN N | Licensed Practical Nurse | Observed placing wound cleanser on floor during wound care |
| IP G | Infection Preventionist | Observed breaching infection control during wound care |
| CNA H | Certified Nursing Assistant | Observed breaching infection control during catheter care |
| RN G | Registered Nurse | Observed breaching infection control during blood sugar testing |
| LPN S | Licensed Practical Nurse | Interviewed about ketoconazole shampoo application |
| LPN U | Licensed Practical Nurse | Interviewed about sleep log order |
| RN R | Registered Nurse | Interviewed about respiratory assessments and diabetic foot care |
| LPN Q | Licensed Practical Nurse | Interviewed about oxygen tubing change |
| LPN BB | Licensed Practical Nurse | Interviewed about smoking supervision |
| CNA Y | Certified Nursing Assistant | Interviewed about ice chest use and contamination |
| OTA L | Occupational Therapy Assistant | Interviewed about providing shower to resident |
Inspection Report
Complaint Investigation
Deficiencies: 1
Aug 27, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide adequate supervision to a resident (R3) who eloped from the facility on 7/6/24 and was missing for approximately seven hours.
Findings
The facility failed to ensure adequate supervision of resident R3, who left the facility unsupervised and was found three miles away at his home after nearly seven hours. The facility's policies on elopement prevention and supervision were not properly followed, including staff not verifying resident status before allowing exit. Immediate Jeopardy was identified but later removed after corrective actions were implemented.
Complaint Details
The complaint investigation found that resident R3 eloped from the facility on 7/6/24 and was missing for approximately seven hours. The facility staff did not know his whereabouts, did not verify his identity before allowing him to leave, and failed to provide adequate supervision. Police were involved, and a Silver Alert was issued. The Immediate Jeopardy was removed on 7/12/24 after corrective actions were implemented.
Severity Breakdown
Immediate jeopardy: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure adequate supervision to prevent accidents and elopements for resident R3 who eloped and was missing for seven hours. | Immediate jeopardy |
Report Facts
Duration resident missing: 7
Distance resident found from facility (miles): 3
Date of elopement: Jul 6, 2024
Date of survey completion: Aug 27, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA F | Certified Nursing Assistant | New employee who let resident R3 out of the building without verifying his identity or supervision needs. |
| NHA A | Nursing Home Administrator | Notified of Immediate Jeopardy and involved in corrective actions. |
| MR E | Manager on Duty | Contacted administration and police after resident was missing; reviewed camera footage. |
| DON B | Director of Nursing | Reviewed camera footage, involved in root cause analysis and corrective education. |
| POA G | Power of Attorney | Contacted facility and resident; provided information about resident's whereabouts and ride home. |
| VPCS C | Vice President of Clinical Services | Interviewed regarding root cause analysis of elopement incident. |
| PO H | Police Officer | Dispatched to facility and resident's home during elopement incident. |
Inspection Report
Complaint Investigation
Deficiencies: 9
Jun 19, 2024
Visit Reason
The inspection was conducted based on complaints regarding resident rights, visitation restrictions, notification of changes, confidentiality breaches, care planning, activities of daily living, pain management, pharmaceutical services, and environmental safety concerns at Madison Health and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to treat residents with respect and dignity, unreasonable visitation restrictions causing psychosocial harm, failure to notify guardians of significant changes, breach of confidentiality of resident health information, incomplete baseline care plans, inadequate assistance with activities of daily living, failure to provide timely and adequate pain management, and pharmaceutical service deficiencies including delays in medication acquisition and administration. Additionally, the facility allowed unsafe charging of electric wheelchairs in resident rooms.
Complaint Details
The complaint investigation focused on allegations of disrespectful treatment, visitation restrictions, failure to notify guardians of changes, confidentiality breaches, inadequate care planning, insufficient assistance with activities of daily living, poor pain management, and pharmaceutical service deficiencies. The investigation substantiated these concerns with evidence from interviews, record reviews, and observations.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Level of Harm - Actual harm: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to honor resident's right to be treated with respect and dignity, including timely laundry services for resident R4. | Level of Harm - Minimal harm or potential for actual harm |
| Unreasonable visitation restrictions imposed on resident R5's husband, causing depression, financial hardship, and disinterest in activities of daily living. | Level of Harm - Actual harm |
| Failure to immediately notify resident R4's guardian of emergency room transfer and falls. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to keep resident R18's personal health information confidential, found in another resident's room. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement a baseline care plan within 48 hours for resident R3. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide scheduled weekly showers for residents R4 and R15 as documented. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure a safe environment by allowing resident R5 to charge her electric wheelchair in her room, contrary to facility policy. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide safe and appropriate pain management for residents R6 and R5, including delays in medication acquisition and administration, resulting in emotional distress and uncontrolled pain. | Level of Harm - Actual harm |
| Failure to provide pharmaceutical services that assure accurate acquiring, receiving, dispensing, and administering of medications for residents R6 and R5, including delays due to pharmacy and communication issues. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 19
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
Medication delay duration: 22
Medication delay duration: 16
Medication delay duration: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| FM C | Family Member | Provided information regarding laundry delays and confidentiality breach. |
| HH F | Head Housekeeper | Discussed laundry service delays for resident R4. |
| DON B | Director of Nursing | Interviewed regarding visitation restrictions, notification policies, pain management, and pharmaceutical services. |
| SW D | Social Worker | Signed visitation restriction document and was unaware of wheelchair charging issue. |
| NHA A | Nursing Home Administrator | Discussed visitation restrictions and safety concerns related to R5's husband. |
| CNA I | Certified Nursing Assistant | Interviewed about interactions with R5's husband. |
| LPN G | Licensed Practical Nurse | Witnessed aggression from R5's husband and discussed medication acquisition issues. |
| LPN M | Licensed Practical Nurse | Discussed delays in medication acquisition and communication with pharmacy. |
| NP L | Nurse Practitioner | Discussed medication acquisition issues and expectations for nursing staff. |
| AD Q | Activities Director | Interviewed about wheelchair charging policy and practice. |
| CNA H | Certified Nursing Assistant | Reported no problems with R5's husband and expressed concern about visitation restrictions. |
| LPN P | Licensed Practical Nurse | Administered medications to R5 and discussed medication supply issues. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Mar 7, 2024
Visit Reason
The inspection was conducted based on complaints regarding failure to notify a physician of elevated blood glucose levels for one resident and misappropriation of a resident's medication by a nurse.
Findings
The facility failed to notify the physician of elevated blood glucose levels for one resident with diabetes and failed to prevent misappropriation of Oxycodone by a registered nurse for another resident. Investigations confirmed the diversion of medication by the nurse.
Complaint Details
The complaint investigation substantiated that the facility failed to notify the physician about elevated blood glucose levels for Resident 9 and confirmed diversion of Oxycodone by Registered Nurse 1 from Resident 19.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to notify the physician of elevated blood glucose levels for 1 of 3 residents reviewed for diabetes. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a resident was free from misappropriation of property when a nurse diverted Oxycodone for 1 of 6 residents reviewed for misappropriation. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for diabetes: 3
Residents reviewed for misappropriation: 6
Total residents in sample: 25
Blood glucose level: 421
Medication doses diverted: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN2 | Registered Nurse | Did not notify physician of elevated blood glucose levels for Resident 9. |
| RN1 | Registered Nurse | Diverted Oxycodone medication from Resident 19. |
| LPN1 | Licensed Practical Nurse | Reported concerns about Resident 19's Oxycodone medication and pain levels. |
| Director of Nursing | Director of Nursing | Confirmed failure to notify physician and diversion of medication; involved in investigation. |
| President of Clinical Services | President of Clinical Services | Involved in investigation confirming diversion of Oxycodone by RN1. |
Inspection Report
Routine
Deficiencies: 2
Jan 4, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of care related to pressure ulcer prevention and food safety in the facility.
Findings
The facility failed to provide appropriate pressure ulcer care for one resident, resulting in the development and worsening of a stage 2 pressure ulcer to an unstageable ulcer. The facility also failed to ensure proper storage of food items, specifically unopened Mighty Shakes left unrefrigerated on a resident's windowsill.
Severity Breakdown
Level of Harm - Actual harm: 1
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure a resident receives care to prevent pressure ulcers, resulting in actual harm with development of an unstageable pressure ulcer. | Level of Harm - Actual harm |
| Failed to store and serve food in accordance with professional standards; observed 6 unopened Magic Shakes stored on resident's windowsill unrefrigerated. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Braden Scale score: 14
Braden Scale score: 12
Wound measurements: 8
Wound measurements: 6
Wound measurements: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON B | Director of Nursing | Interviewed regarding pressure ulcer risk, interventions, and food storage practices. |
| RCS F | Regional Clinical Specialist | Interviewed jointly with DON B about wound care and pressure ulcer staging. |
| Maintenance Director G | Interviewed about mattress installation and maintenance. | |
| CNA D | Certified Nursing Assistant | Interviewed about resident repositioning frequency. |
| LPN H | Licensed Practical Nurse | Interviewed about pressure ulcer risk assessment and wound care. |
| CNA I | Certified Nursing Assistant | Interviewed about resident wound status on admission. |
| RR E | Resident Representative | Interviewed about resident repositioning and food storage. |
| FV C | Family Visitor | Interviewed about resident's time spent in wheelchair. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Dec 21, 2023
Visit Reason
The inspection was conducted due to concerns about the facility's failure to ensure safe smoking practices for residents assessed as supervised smokers, as well as issues related to food temperature and medication administration documentation.
Findings
The facility failed to ensure safe smoking practices for 4 residents who required supervision while smoking, resulting in immediate jeopardy that was later removed. Additionally, the facility did not ensure food was served at safe and palatable temperatures for 9 residents, and medication administration records for one resident were incomplete with missing documentation of administered doses.
Complaint Details
The complaint investigation focused on unsafe smoking practices by residents who required supervision, leading to immediate jeopardy due to fire risk with oxygen use. The immediate jeopardy was removed after corrective actions. Additional complaints involved food temperature and medication administration documentation.
Severity Breakdown
Level E: 1
Level G: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure safe smoking practices for residents assessed as supervised smokers, including allowing residents to keep smoking materials contrary to care plans and facility policy. | Level E |
| Failure to ensure food and drink were served at safe and appetizing temperatures, with test trays showing cold food and resident complaints. | Level G |
| Failure to maintain complete and accurate medication administration records for a resident, with multiple doses not signed out on the MAR. | Level G |
Report Facts
Residents affected by smoking deficiency: 4
Residents affected by food temperature deficiency: 9
Medication doses not signed out: 6
Smoking frequency for R4: 10
Smoking frequency for R6: 2
Smoking frequency for R7: 5
Smoking frequency for R8: 2
Food temperature - pork: 102.7
Food temperature - breaded cauliflower: 123
Food temperature - mashed potatoes: 124
Food temperature - milk: 51.2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN E | Licensed Practical Nurse | Interviewed regarding observation of resident R4 smoking in room with oxygen running. |
| DON B | Director of Nursing | Interviewed regarding smoking policy, resident supervision, and medication administration records. |
| NHA A | Nursing Home Administrator | Interviewed regarding knowledge of smoking incidents and facility policy. |
| DM C | Dietary Manager | Interviewed regarding supervision of smokers and storage of smoking materials. |
| AD F | Activity Director | Interviewed regarding supervision of smokers and storage of smoking materials. |
| LPN D | Licensed Practical Nurse | Interviewed regarding medication administration record documentation. |
| DD C | Dietary Director | Interviewed regarding resident concerns about food temperature. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Aug 30, 2023
Visit Reason
The inspection was conducted following a complaint regarding the facility's failure to maintain personal privacy during personal cares and incomplete and inaccurate medical record documentation for resident R4.
Findings
The facility failed to maintain personal privacy for resident R4 by allowing non-direct care staff to be present during personal cares, which made the resident and staff uncomfortable. Additionally, the facility did not maintain complete and accurate medical records for R4, including missing documentation of medication administration and wound care treatments.
Complaint Details
The complaint investigation found substantiated issues related to personal privacy violations and incomplete medical record documentation for resident R4.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility did not maintain personal privacy during personal cares for resident R4 by allowing non-direct care staff to be the second person in the room. | Level of Harm - Minimal harm or potential for actual harm |
| Facility did not maintain complete and accurate medical records for resident R4, including missing documentation on the Medication Administration Record (MAR) and Treatment Administration Record (TAR). | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents Affected: 1
Dates of missing documentation: 1
Dates of missing documentation: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA D | Certified Nursing Assistant | Named in privacy deficiency for pulling non-care staff to be second person during cares |
| Hskp E | Housekeeper | Named as non-care staff pulled to be second person during cares |
| SS F | Social Services | Named as non-care staff pulled to be second person during cares |
| Rec G | Receptionist | Named as non-care staff pulled to be second person during cares |
| RN CS C | Registered Nurse Clinical Support | Provided statements regarding expectations for care staff presence and documentation |
| NHA A | Nursing Home Administrator | Referenced in discussion about acceptability of non-care staff presence during cares |
Inspection Report
Routine
Deficiencies: 6
Jun 7, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including grievance processes, medication administration, emergency preparedness, pharmaceutical services, and medication error rates.
Findings
The facility failed to file grievances as required, had issues with medication administration including missed doses and unavailable medications, inconsistent crash cart maintenance, incomplete narcotic counts, and labeling deficiencies on medications. Medication errors were not consistently reported to providers, and expired insulin was administered.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to file grievances per facility policy for a resident's multiple missed medications. | Level of Harm - Minimal harm or potential for actual harm |
| Inadequate monitoring and stocking of emergency crash carts; missing supplies and inconsistent checklist completion. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure quality control checks on blood glucose meters were completed consistently. | Level of Harm - Minimal harm or potential for actual harm |
| Multiple medication administration errors including missed doses and failure to notify providers. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to complete and sign narcotic counts at every shift change. | Level of Harm - Minimal harm or potential for actual harm |
| Administration of expired insulin and failure to label insulin vials properly. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication error rate: 10
Narcotic count signature blanks: 113
BIMS scores: 9
BIMS scores: 11
BIMS scores: 14
BIMS scores: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| NHA A | Nursing Home Administrator | Facility Grievance Official and interviewed regarding grievance and medication error processes |
| IDON B | Interim Director of Nursing | Interviewed regarding medication errors, narcotic counts, crash cart maintenance, and insulin labeling |
| LPN C | Licensed Practical Nurse | Observed preparing and administering expired insulin without proper labeling |
| LPN F | Licensed Practical Nurse | Interviewed about narcotic counts and crash cart responsibilities |
| LPN D | Licensed Practical Nurse | Interviewed about narcotic counts and medication availability |
| LPN E | Licensed Practical Nurse | Interviewed about crash cart checklist and maintenance |
| LPN I | Licensed Practical Nurse | Interviewed about medication availability and notification of providers |
| NP J | Nurse Practitioner | Interviewed regarding lack of notification of missed medications |
| FM H | Family member interviewed about concerns of missed medications and grievance process | |
| R4 | Resident interviewed about missed medications and grievance process |
Inspection Report
Routine
Deficiencies: 11
May 4, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, nutrition, infection control, and documentation at Madison Health and Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to notify providers of significant weight changes, inadequate investigation of neglect allegations, inconsistent wound care and pressure injury management, inadequate supervision during meals for residents with swallowing difficulties, failure to maintain signed physician orders, poor pain management, and improper infection control practices.
Deficiencies (11)
| Description |
|---|
| Failure to notify the physician with a change in weight for 2 residents reviewed for weight changes. |
| Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. |
| Failure to thoroughly investigate allegations of neglect or misappropriation of resident property. |
| Failure to provide treatment and care according to orders, resident’s preferences and goals, including inconsistent wound care and lack of weekly wound assessments. |
| Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including failure to complete weekly skin assessments and follow care plan interventions. |
| Failure to ensure adequate supervision, assistance, and interventions to prevent accidents for a resident with swallowing difficulties. |
| Failure to provide enough food/fluids to maintain a resident's health, including inadequate nutrition monitoring, weight management, and failure to provide recommended supplements. |
| Failure to provide safe, appropriate pain management for a resident, including failure to administer scheduled pain medication prior to wound care. |
| Failure to ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. |
| Failure to ensure food was palatable and served at a safe and appetizing temperature, including hot foods not served hot. |
| Failure to provide and implement an infection prevention and control program, including improper disinfection of glucometer with alcohol wipes instead of EPA registered disinfectant. |
Report Facts
Weight: 123.8
Weight: 119.3
Weight: 95
Weight: 102.1
Weight loss percentage: 14.4
Weight loss percentage: 15.1
Braden Score: 16
Braden Score: 11
Wound length: 2.5
Wound width: 1.6
Wound length: 1
Wound width: 1.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner D | Nurse Practitioner | Interviewed regarding weight gain notification and pain management |
| Interim Director of Nursing B | Interim Director of Nursing | Interviewed regarding weight gain notification, investigation of neglect, wound care, pain management, and physician orders |
| Director of Nursing B | Director of Nursing | Interviewed regarding neglect allegation reporting |
| Social Worker U | Social Worker / Grievance Officer | Interviewed regarding grievance investigations |
| Nursing Home Administrator A | Nursing Home Administrator | Interviewed regarding neglect investigations and narcotic misappropriation |
| Regional Dietician K | Regional Dietician | Interviewed regarding meal tray preparation and nutrition management |
| Rehab Director L | Rehabilitation Director | Interviewed regarding meal supervision and nutrition management |
| RN E | Registered Nurse | Observed and interviewed regarding wound care and pain management |
| LPN T | Licensed Practical Nurse | Interviewed regarding wound care and pain medication administration |
| Hospice RN F | Hospice Registered Nurse | Interviewed regarding wound care and pain management |
| CNA G | Certified Nursing Assistant | Interviewed regarding nutrition and weight monitoring |
| LPN V | Licensed Practical Nurse | Observed and interviewed regarding glucometer disinfection |
Inspection Report
Annual Inspection
Census: 63
Deficiencies: 9
Mar 23, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care, including resident care, medication administration, staffing, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to ensure resident participation in care planning, inadequate assistance with activities of daily living, insufficient RN staffing, inaccurate nurse staffing postings, pharmaceutical service deficiencies including medication errors and delays, incomplete documentation of neurological assessments after a fall, improper hand hygiene practices, and unsafe, unclean, and uncomfortable facility environment conditions.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Level of Harm - Potential for minimal harm: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failure to allow resident or representative to participate in care planning. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide necessary care and assistance for activities of daily living for residents unable to perform them. | Level of Harm - Minimal harm or potential for actual harm |
| Did not use services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. | Level of Harm - Minimal harm or potential for actual harm |
| Did not post accurate nurse staffing information daily at the beginning of each shift. | Level of Harm - Potential for minimal harm |
| Pharmaceutical services failed to meet resident needs including unclear medication orders, missed doses, delayed medications, and reliance on residents to determine medication doses. | Level of Harm - Minimal harm or potential for actual harm |
| Medication error rate exceeded 5%, with 37 errors out of 50 opportunities observed during medication pass. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to document complete and accurate neurological assessments after an unwitnessed fall with head injury. | Level of Harm - Minimal harm or potential for actual harm |
| Staff did not consistently perform proper hand hygiene before donning and after removing gloves during dressing changes. | Level of Harm - Minimal harm or potential for actual harm |
| Facility environment was unsafe, unclean, and uncomfortable with issues including insecure exterior handrails, uneven and cracked flooring, separated carpet, holes and unpainted sheetrock, brown spots on ceiling, worn shower doors, rusty refrigerator, dirty air vents and light fixtures, and pervasive odors. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 63
Residents affected: 6
Residents affected: 7
Residents affected: 1
Residents affected: 3
Residents affected: 63
Medication administration errors: 37
Medication administration opportunities: 50
Medication administration error rate: 74
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN M | Licensed Practical Nurse | Named in medication administration errors and pharmaceutical services deficiencies |
| UM F | Unit Manager | Named in medication administration errors, pharmaceutical services deficiencies, and hand hygiene deficiencies |
| NHA A | Nursing Home Administrator | Interviewed regarding RN staffing, nurse staffing postings, medication errors, facility environment |
| UM L | Unit Manager | Interviewed regarding care conference notification, neurological assessment documentation, medication administration |
| RN N | Registered Nurse | Interviewed regarding unclear medication order for resident R8 |
| HN R | Hospice Nurse | Interviewed regarding medication administration to resident R4 |
| MD G | Maintenance Director | Interviewed regarding facility environment and maintenance issues |
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