Inspection Reports for
The Madison Health and Rehabilitation Center

Complaint investigation CI MS#26995 was reviewed and found to be corrected; no deficiencies were cited.

The State Agency is recommending that the facility be placed back in compliance effective 07/06/26. No deficiencies were cited in this desk review.

Complaint Investigations MS #3016973 and MS #2995773 were conducted. MS #3016973 related to nursing and educational services had no deficiencies cited. MS #2995773 related to infection control, quality of care and nursing services resulted in deficiencies M615 and M1570.

Two deficiencies were cited related to wound care and infection control for Resident #2. The facility failed to ensure the wound vacuum was monitored and maintained in working order and failed to implement effective infection prevention practices including hand hygiene and use of gowns.

Complaint Investigations CI MS #3016973 and CI MS #2995773 were conducted. CI MS #3016973 related to nursing and educational services found no deficiencies. CI MS #2995773 related to infection control, quality of care, and nursing services resulted in deficiencies F880, F656, and F686.

The facility was found not in compliance with infection prevention and control, care planning, and pressure ulcer treatment requirements related to Resident #2. Deficiencies included failure to follow Enhanced Barrier Precautions, improper wound care practices, and failure to maintain a functioning Negative Pressure Wound Therapy device.

CI MS#26995 complaint investigation was reviewed and found to be in compliance with no deficiencies cited.

The State Agency found the facility in compliance and recommended it be placed back in compliance effective 05/04/26.

Complaint 2965461 and Complaint (Incident) 2961832 investigated related to misappropriation, medication storage and medication administration. Deficiency M500 was cited.

The facility was found not in compliance with Minimum Standards and cited M500 for failing to prevent misappropriation of scheduled medication for one resident. The investigation revealed tampering with Resident #1's clonazepam medication, with two tablets removed and replaced with unidentified tablets, and the facility was unable to determine who was responsible.

Complaint 2965461 and Complaint (Incident) 2961832 were investigated related to misappropriation, medication storage and medication administration. Deficiency F0602 was cited.

F0602 - The facility failed to prevent the misappropriation of scheduled medication for one of four sampled residents, Resident #1, when two clonazepam tablets were tampered with and replaced by unidentified tablets. The facility investigated but was unable to determine who tampered with the medication, and the resident was assessed with no adverse effects.

Complaint Investigation (CI), MS #493600, MS#493602, MS#493604 related to staffing and quality of care concerns. The SA determined the facility was in compliance with no deficiencies cited.

The facility was found to be in compliance with the requirements of participation in Medicare and Medicaid and there were no deficiencies cited.

The SA is recommending that your facility be placed back in compliance effective 02/14/25. No deficiencies were cited in this desk review.

The survey included two complaint investigations (CI MS #27198 and CI MS #27119) related to Activities of Daily Living and implementing a care plan. Deficiencies were cited at F656 and F677 related to these complaints.

The facility was found not in compliance with Medicare and Medicaid participation requirements and cited multiple deficiencies including failure to honor resident rights for advanced directives, inaccurate assessments, incomplete care plans, inadequate ADL care, improper medication storage, failure to provide adaptive eating equipment, unsanitary food storage, and failure to follow infection control precautions.

The facility was found deficient in honoring residents' rights to make healthcare decisions, accurately coding assessments, implementing comprehensive care plans, providing adequate ADL care including oral hygiene and nail care, properly storing medications, ensuring adaptive feeding equipment was provided, maintaining proper food labeling and storage, and following enhanced barrier precautions for infection control.

There were no Life Safety Code deficiencies cited during this survey; the facility met the applicable provisions of the 2012 Edition of the Life Safety Code.

Complaint CL MS #25494 regarding quality of care - incontinent care was investigated and found to be unsubstantiated with no deficiencies cited.

The facility was found in compliance with the requirements of participation in Medicare and Medicaid Services and no deficiencies were cited.

The State Agency is recommending that the facility be placed back in compliance effective 10/31/23. No deficiencies were cited in this desk review.

The facility failed to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day period, potentially causing more than minimal harm to all residents.

F0689 - The facility failed to safely store and lock hazardous cleaning chemicals on four of five housekeeping carts observed during the annual survey, leaving chemicals unattended and carts unlocked in multiple locations.

The facility met the applicable provisions of the 2012 Edition of the Life Safety Code. There were no Life Safety Code deficiencies cited during this survey.

The facility failed to safely store and lock hazardous cleaning chemicals on four of five housekeeping carts observed. Multiple observations and interviews confirmed that chemicals were left unattended and unlocked, posing potential harm to residents. The housekeeping supervisor and staff lacked proper training and keys to secure the carts, despite receiving in-service training earlier in the year.

The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

No health deficiencies were found during the survey.

The information provided by the facility confirmed the facility was in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm. The SA is recommending your facility be placed back in compliance effective 05/31/22.

The SA is recommending that the facility be placed back in compliance effective 05/31/22. No deficiencies are cited in this document.

The facility failed to provide the generator in accordance with NFPA 110 section 4.1, as the generator did not transfer power to the facility within 10 seconds during testing on 4/6/22. Repairs were made and subsequent testing on 4/8/22 showed the generator transferred power within 8 seconds.

The survey included complaint investigations CI MS #18572 and CI MS #18185. The SA substantiated CI MS #18572 for Quality of Care and Residents Rights citing F550 and F677. The SA did not substantiate CI MS #18185 for employee to resident abuse.

The survey found multiple deficiencies including failure to treat residents with dignity, incomplete PASARR screenings, inadequate comprehensive care plans, improper catheter bag privacy, insufficient supervision of wandering residents, unlabeled tube feedings, unsafe food thawing and storage, infection control lapses during medication administration, incomplete COVID-19 staff vaccination compliance, and inadequate call light system volume.

The facility was found deficient in multiple areas including failure to maintain resident dignity and privacy, incomplete PASARR screenings, inadequate comprehensive care plans, improper monitoring of wandering residents, improper labeling of feeding tubes, food safety violations, infection control lapses during medication administration, and failure to ensure staff COVID-19 vaccination compliance. Additionally, the call light system volume was insufficient to alert staff timely.

The facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6).

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

The facility failed to report complete information about COVID-19 to the CDC's NHSN during a seven-day period as required by regulation.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

CI MS #16372 concerned quality of care/treatment including resident left wet extended periods, call bell not answered timely, and food served cold; these concerns were not substantiated. CI MS #16439 concerned employee to resident abuse; this concern was not substantiated. No deficiencies were cited for either complaint.

The facility was found to be in substantial compliance with requirements for participation in Medicare and Medicaid. No deficiencies were cited during this abbreviated survey.

The facility was found not in compliance with multiple deficiencies related to care planning, accident prevention, catheter care, nursing competency, medication management, food safety, and infection control. Deficiencies were cited for failure to implement care plans, secure residents during transport, provide proper catheter care, complete nurse competencies, label medications correctly, maintain sanitary food service, and follow infection control protocols.

Complaint MS #15875 was substantiated for accidents when a CNA failed to use a mechanical lift and two-person assistance as required by the assessment and care plan, resulting in a fall and Right Tibia Fracture to Resident #1 on 4/19/19. The CNA was terminated and corrective actions were implemented.

The facility failed to follow Resident #1's plan of care for use of a lift and two-person assistance during transfer, resulting in a fall and Right Tibia Plateau fracture. The CNA involved was terminated, and the facility implemented corrective measures including staff education, competency checks, audits, and quality assurance meetings. The facility was found in substantial compliance as of 5/6/19.