Madison Health: Infection Control Failures Spread ESBL - WI
The facility's infection preventionist admitted he couldn't remember whether he had implemented proper precautions for any of the four residents who tested positive for extended-spectrum beta-lactamase (ESBL), a multi-drug resistant organism that spreads easily through contaminated hands and surfaces.
The outbreak began in January when a resident with chronic kidney disease tested positive for ESBL in her urine. Lab results specifically warned that "isolation precautions may be required," but the facility's surveillance records show no isolation measures were taken.
Within a month, three more residents on the same hallway contracted ESBL infections.
Federal inspectors found that nursing assistants threw soiled linens on the floor during bed baths, failed to wash their hands between caring for different body parts of the same resident, and never offered hand hygiene to residents before meals. Staff interviewed during the March inspection said they had received no recent training on multi-drug resistant organisms or proper precautions.
"Having four positive cases of ESBL within a short period of time in the facility is concerning with possible spread of a MDRO," the infection preventionist told inspectors, using the abbreviation for multi-drug resistant organism.
ESBL-producing bacteria are resistant to common antibiotics and require complex treatments. The Centers for Disease Control warns these infections occur frequently in nursing homes and can spread from person to person through dirty hands and surfaces.
The first resident, identified as R223 in the inspection report, had her urine tested on January 1, 2025. Results showed two types of bacteria, including Proteus mirabilis ESBL at levels indicating infection. The lab report specifically noted the organism was "an extended-spectrum beta-lactamase producer" and warned that "isolation precautions may be required."
Despite this clear guidance, the facility's surveillance list for January shows "N/A" under the type of isolation column for R223. CDC guidelines recommend enhanced barrier precautions, including gloves and gowns during high-contact resident care, for residents with ESBL infections.
By February, the infection had spread to three residents living on the 100 hallway. R32 tested positive on February 3 for Citrobacter freundii complex-ESBL. R44 tested positive February 18 for Proteus vulgaris-ESBL. R47 tested positive February 17 for Klebsiella oxytoca-ESBL.
All three surveillance records again listed "N/A" for isolation precautions.
When inspectors interviewed the infection preventionist about R223's case, he said MDRO precautions "would have been put into place." But when shown the facility's own records indicating no isolation measures, he replied, "I don't know why I put N/A in there. I thought I had put precautions into place but can't remember for sure."
He later acknowledged he had "no documentation to show the residents were on precautions."
The Director of Nursing confirmed that multiple ESBL cases on the same hallway "should have been recognized" as a concern requiring staff education and isolation precautions. She said it was worrying because of "the spread to others and of course the concern of antibiotic resistance."
Staff knowledge gaps were evident throughout the inspection. Three nursing assistants told inspectors they were unaware of any residents with multi-drug resistant organisms or what precautions would be required for such residents. One licensed practical nurse said she "was not aware of residents with MDROs" but knew such residents would require transmission-based precautions.
Inspectors observed repeated hand hygiene failures during routine care. During wound care for one resident requiring enhanced barrier precautions, a registered nurse and nursing assistant entered the room without proper gowns, changed gloves multiple times without washing hands, and moved between contaminated and clean areas without hand hygiene.
The nurse later admitted to inspectors she had "missed opportunities for hand hygiene" and should have performed hand hygiene "before starting wound care" and "after taking off soiled gloves and before applying clean gloves."
During a bed bath for another resident, a nursing assistant removed gloves to check her phone, applied new gloves without hand hygiene, threw soiled clothing and linens on the floor, and used the same dirty gloves to brush the resident's hair and adjust clothing after transferring her to a wheelchair.
When questioned, the assistant acknowledged she should have performed hand hygiene "4 to 5 times during bed bath" and said throwing dirty laundry on the floor was inappropriate, though she claimed "that is what they do here" because the facility lacked proper containers in rooms.
The Director of Nursing contradicted this, saying the facility had "special containers" for dirty clothes on each unit and that staff should put soiled items "in a plastic bag" during care.
Staff also failed to offer hand hygiene to residents before meals. Two nursing assistants observed passing meal trays acknowledged they should offer residents hand sanitizer before eating but said they hadn't done so.
The facility's antibiotic stewardship program also showed significant gaps. One resident was treated with antibiotics for a urinary tract infection despite lab results showing no infection. The infection preventionist acknowledged the resident "absolutely" should not have been treated, saying "R73 did not have a UTI but family wanted her on antibiotic."
Two other residents received prophylactic antibiotics without documented justification or discussion of risks and benefits with their physicians, contrary to the facility's own antibiotic stewardship policy.
The facility's infection control policies had not been reviewed annually as required. Several policies dated back to 2022 and 2023, with no evidence of recent updates despite the policy requirement for annual review.
The infection preventionist told inspectors that policies were reviewed yearly by the Director of Nursing and administrator, but when asked for evidence, he said he would "have to check." No documentation was provided during the inspection.
The outbreak highlighted broader systemic failures in infection prevention. The facility's policy required surveillance systems to prevent and control infections, staff education on infection control practices, and prompt response to outbreaks. The policy specifically stated that "three or more cases" of infection in a short period should trigger an investigation.
Despite having four ESBL cases within two months, three on the same hallway, no outbreak investigation was initiated. No additional staff training was provided. No enhanced cleaning protocols were implemented.
The nurse practitioner caring for some of the infected residents told inspectors she was unaware of the multiple ESBL cases and would have wanted to be notified. She said the facility should "follow the proper precautions which would include gown and gloves and the standard precautions for ESBL" and should "review who has been taking care of those residents."
The inspection found actual harm to the four residents who contracted ESBL infections and potential harm to other residents due to inadequate hand hygiene and infection control practices.
Federal regulations require nursing homes to maintain infection prevention programs designed to provide safe environments and prevent transmission of communicable diseases. The failures at Madison Health and Rehabilitation Center represent violations of these fundamental safety requirements, putting vulnerable residents at risk for preventable infections that are increasingly difficult to treat.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Madison Health and Rehabilitation Center from 2025-03-25 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 HEALTH AND REHABILITATION CENTER in MADISON, WI was cited for violations during a health inspection on March 25, 2025.
The outbreak began in January when a resident with chronic kidney disease tested positive for ESBL in her urine.
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.