Madison Health And Rehabilitation
Madison Health and Rehabilitation in Mars Hill, NC — inspection on August 27, 2025.
Found 1 citation. 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
examples of roommate incompatibility, which may also be considered abuse.
These examples were: verbal bickering; complaints of inability to complete normal tasks; evidence of residents' withdrawal from others; or desire to stay out of his or her room.
These in-services included reporting procedures for staff should the event occur off hours.
Any active staff determined not to receive the in-service prior to August 6, 2025, will receive in-servicing by the Director of Nursing, Administrator, or designee prior to working.
All education included in the plan was added to the general orientation after 8/5/25.
Any new staff will be educated before working by the Payroll Coordinator during general orientation.
The Administrator will track to ensure all new employees have been educated. On August 5, 2025, the Regional Operator educated the Administrator and the Director of Nursing on conducting random daily observations of resident-to-resident interactions and staff to resident interactions for any sign of incompatibility or abuse.
The Administrator added observations of resident compatibility to the Daily Rounding form to be completed by the Interdisciplinary Team to be discussed at morning meeting. On August 5, 2025, the Administrator educated the IDT on the new observations on the rounding form.Indicate how the facility plans to monitor its performance to make sure solutions are sustained:To ensure quality assurance, the Administrator, Director of Nursing, or designated member of management will randomly interview 5 staff members per week for two weeks, 3 staff members per week for two weeks, and 2 staff members per week for an additional month.
The interview will consist of the following questions: Have you had any observations that indicate signs of abuse, resident-to-resident altercations, or signs of roommate incompatibility? Any necessary follow-up or education will be provided immediately and documented.
Results of these interviews will be presented in the QAPI Committee Meeting for a minimum of two consecutive meetings, at which time a need for additional monitoring will be determined.To ensure quality assurance, the Social Worker or designated member of management will interview five residents per week for four consecutive weeks.
The interview will ensure the residents feel safe, don't have unresolved concerns, are comfortable in their current room setting, and are being treated well.
Any necessary follow-up will be reported to the Director of Nursing, Social Worker, or Administrator.
Findings of these interviews will be presented in the upcoming QAPI Committee Meeting following completion of the four consecutive weeks.
The committee will review and determine the need for further monitoring.Any room changes initiated as a result of roommate incompatibility will be reviewed for three consecutive QAPI Committee Meetings to ensure resolution and [NAME][TRUNCATED]
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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.