The Madison Health And Rehab
THE MADISON HEALTH AND REHAB in MADISON, MS — inspection on May 27, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During the provision of care, Certified Nursing Assistant (CNA) #1 was observed providing hands on care without wearing a gown despite the resident being identified for Enhanced Barrier Precautions.
During an interview on 05/26/26 at 2:45 PM, CNA #1 confirmed she did not wear a gown while providing incontinent care to Resident #2. CNA #1 stated she should have worn a gown to prevent the spread of infection and to comply with the resident's Enhanced Barrier Precautions. CNA #1 further stated residents requiring Enhanced Barrier Precautions are identified by a green dot displayed outside the resident's room.
During an interview on 05/27/26 at 9:15 AM, the Director of Nursing (DON) stated staff are expected to follow Enhanced Barrier Precautions when caring for residents with chronic wounds or indwelling medical devices to prevent infection transmission.
The DON further stated staff should perform appropriate hand hygiene and utilize required personal protective equipment during resident care.
During an interview on 05/27/26 at 1:05 PM, the facility's care plan nurses stated Enhanced Barrier Precautions should have been followed during incontinent care for Resident #2 as directed in the resident's care plan.
The care plan nurses stated failure to follow resident specific care plan interventions could increase the risk of infection transmission and compromise resident safety.
They further stated the purpose of the care plan is to direct staff regarding the individualized care needs of each resident.During a follow up interview on 05/27/26 at 2:25 PM, the DON confirmed Resident #2's care plan was not followed when CNA #1 failed to wear a gown during incontinent care.
The DON stated the resident's chronic Stage IV sacral wound required Enhanced Barrier Precautions and acknowledged that failure to follow those precautions could increase the risk of wound infection.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
255276 05/27/2026
The Madison Health and Rehab 111 Kelly Blvd Madison, MS 39110
Summary Report with active orders as of 5/27/26 revealed an order dated 04/24/26 for treatment of a Stage IV sacral pressure injury with Negative Pressure Wound Therapy at 125 mmHg (millimeters of mercury) continuous pressure with dressing changes every Monday, Wednesday, and Friday and as needed.
During an observation on 05/26/26 at 12:30 PM, Resident #2's wound vacuum machine was observed connected to the resident but not functioning.
The screen was not illuminated, no sounds were emitted from the unit, and no drainage was observed moving through the tubing.During a follow up observation on 05/26/26 at 2:30 PM, while incontinent care was being provided, the wound vacuum remained connected to the resident and continued to be nonfunctional.
Following completion of incontinent care, the wound vacuum dressing was observed to have lost its seal and become detached.
During an interview on 05/26/26 at 2:45 PM, Certified Nurse Assistant (CNA) #1 stated she was unaware the wound vacuum was not functioning prior to providing care and indicated she would notify the wound care nurse. Resident #2 and her granddaughter stated the resident frequently remains incontinent for extended periods despite using the call light.
They stated the resident has a chronic Stage IV sacral wound and urine often causes the wound vacuum dressing to lose its seal.
They further stated staff do not routinely monitor the wound vacuum's function.
They reported that on the day of observation, Resident #2 returned from physical therapy wet with urine, called for assistance multiple times, and no staff responded before incontinent care was eventually provided.
They stated the wound vacuum was not functioning during therapy and remained nonfunctional afterward.
During an interview on 05/27/26 at 9:05 AM, Licensed Practical Nurse (LPN) #1, the wound care nurse, stated staff had been instructed to notify her if a wound vacuum was not working and to apply a wet to dry dressing if the device became nonfunctional until she could assess the resident.
She stated no staff member notified her at approximately 12:30 PM on 05/26/26 that the wound vacuum was not functioning.
She further stated she first became aware of the issue at approximately 2:45 PM when notified by CNA #1 after incontinent care had been completed. At that time, she contacted the Nurse Practitioner (NP) who instructed her to apply a wet to dry dressing rather than reapply the wound vacuum.
During an interview on 05/27/26 at 9:15 AM, the Director of Nursing (DON) stated the facility did not have routine checks of wound vacuum functionality in place, such as every two hours.
The DON stated implementing such monitoring may be necessary to ensure devices are functioning properly.
The DON further stated a malfunctioning wound vacuum and prolonged exposure to urine could contribute to wound deterioration and infection.
The DON stated nursing assistants are responsible for checking incontinent residents at least every two hours and providing care as needed to prevent skin breakdown and wound deterioration.
During an interview on 05/27/26 at 2:10 PM, the NP stated a wound vacuum remaining inoperable for periods of time could delay wound healing.
The NP further stated prolonged exposure to urine could contribute to breakdown of the peri wound tissue and reduce the wound's ability to heal.A record review of the admission Record for Resident #2 revealed she was admitted on [DATE] with diagnoses that included nondisplaced fracture of the medial condyle of the right femur.A record review of the Minimum Data Set (MDS) with an Assessment Reference Date of 04/16/26 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #2 was cognitively intact.
255276 05/27/2026
The Madison Health and Rehab 111 Kelly Blvd Madison, MS 39110
04/16/26 revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating Resident #2 was
Pressure Wound Therapy (NPWT) at 125 mmHg continuous pressure with dressing changes every
Barrier Precautions dated 05/26/26.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.