Inspectors classified the violations as causing minimal harm or the potential for actual harm, and noted that a few residents were affected.
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The resident, identified in inspection records as Resident R1, was found on the floor next to her bed on May 2, 2026, at approximately 3:30 p.m.
The resident, identified in inspection records as Resident 5, used a condom catheter.
The incident happened on the evening of January 24, 2026.
An order formalizing those precautions had been placed just one day before inspectors observed the lapse.
The sequence of events began on the evening of May 26.
The inspection that captured this was a complaint survey at The Madison Health and Rehab, conducted May 27, 2026.
The order called for the drug to be given every six hours.
Federal inspectors documented the case during a complaint inspection at the facility on May 27, 2026.
The resident, identified in inspection records as R161, was a known diabetic.
The inspection, completed May 27, identified a failure in the facility's infection prevention and control program.
Resident 43 also had chronic obstructive pulmonary disease.