Belmont Nursing And Rehab Ctr

F-F700 Bed rails .The facility failed to assess the risk for entrapment for residents within the facility. Majority of bed with bed rails and no evaluation .

On 3/12/25 at 1:31 PM, MD Q (Maintenance Director) indicated prior to 3/7/25, he did not complete any kind of measurements or assessments of side rails. MD Q indicated on 3/7/25 the facility removed side rails and completed assessments for residents who have side rails currently. MD Q indicated prior to 3/7/25 the facility would leave side rails on the beds when residents would discharge, and they would be left on bed for next resident. MD Q indicated he now documents his measurements on the assessment form. MD Q is not aware of anything he should be mindful of when installing side rails to beds with air mattresses.

On 3/12/25 at 2:01 PM, PTA R (Physical Therapy Assistant) indicated she helped complete side rail assessments for two residents on 3/7/25. PTA R indicated she was not aware of any system or assessment

in place prior to 3/7/25 for side rails. PTA R indicated the Transfer Bar Use Assessment Form includes risks and benefits of side rails and alternatives are offered/discussed before using a side rail now. PTA R indicated all residents who have side rail bars should now have assessments and measurements.

On 3/11/25 at 9:00 AM, LPN P (Licensed Practical Nurse) indicated she did not realize the concern with side rails and the risk for entrapment. LPN P indicated on 3/7/25 the facility took off many resident side rails and now there is an assessment that must be completed prior to installing side rails. LPN P indicated there was not an assessment or a process prior to 3/7/25.

Surveyors completed sweep of facility on 3/12/25 at 10:00 AM for side rails. Surveyors identified 11 residents who are utilizing air mattresses with side rails.

Example 1

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 40 525074 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525074 B. Wing 03/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Madison Health and Rehabilitation Center 110 Belmont Rd Madison, WI 53714

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Resident R61 was admitted to the facility on [DATE REDACTED] with diagnoses including Alzheimer's disease, stroke, anxiety disorder, and other seizures. Resident R61's most recent Minimum Data Set (MDS) with Assessment Reference Date Level of Harm - Immediate (ARD) of 3/5/25, indicates Resident R61 has a Brief Interview for Mental Status (BIMS) score of 04 indicating Resident R61 is jeopardy to resident health or severely cognitively impaired. Resident R61 has an activated power of attorney. safety Resident R61's Comprehensive Care Plan, states, in part; .Bed Mobility .The resident is totally dependent on 1 staff Residents Affected - Some for repositioning and turning in bed .Transferring .The resident is totally dependent on 2 staff for transferring via hoyer .Resident is Fall Risk .

On 3/6/25, Surveyor observed Resident R61 lying in bed. Resident R61 was observed to have an air mattress with side rails. It is important to note, there is no documentation for Resident R61 of risks and benefits, alternatives tried, measurements, assessments, or signed consents for the use of side rails.

On 3/11/25 at 8:04 AM, DON B indicated Resident R61 does not have any assessments or documentation for side rails because Resident R61 no longer has side rails. DON B indicated Resident R61's side rails were taken off on 3/7/25.

On 3/12/25 at 12:29 PM, POA O (Power of Attorney) indicated Resident R61 has always had side rails on air mattress bed while residing at facility. POA O indicated POA O never signed a consent or had a discussion with facility on risks and benefits. POA O indicated he was told a long bar could be considered a restraint, but not

the side rails that are currently being used.

Example 2

Resident R20 was admitted to the facility on [DATE REDACTED] with diagnoses including obesity, abnormalities of gait and mobility, lack of coordination, repeated falls, and unspecified open wound. Resident R20's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 1/5/25 indicates Resident R20 has a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident R20 is cognitively intact. Resident R20 is own person.

Resident R20's Comprehensive Care Plan, states, in part; .Bed Mobility Assist of 1 with turning side to side and sitting up laying down in bed. Assist of 2 with boost up in bed .

On 3/6/25 Surveyor observed Resident R20 to have air mattress with side rails. It is important to note, there is no documentation for Resident R20 of risks and benefits, alternatives tried, measurements, assessments, or signed consents for the use of side rails.

On 3/11/25 at 8:04 AM, DON B indicated Resident R61 does not have any assessments or documentation for side rails because Resident R61 no longer has side rails. DON B indicated Resident R61's side rails were taken off on 3/7/25.

30992

Example 3

Resident R65 was admitted to the facility 11/4/24 with diagnoses including, but not limited to, the following: cerebral infarction (stroke), contractures bilateral knees (when muscles, tendons, joints tighten or shorten causing a deformity), reduced mobility (inability to move freely), osteoarthritis (degenerative disease that worsens over time causing pain and stiffness) of knee.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 40 525074 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525074 B. Wing 03/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Madison Health and Rehabilitation Center 110 Belmont Rd Madison, WI 53714

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 Resident R65's most recent Minimum Data Set (MDS) dated [DATE REDACTED] documents, a score of 13 on his Brief Interview of Mental Status (BIMS), which indicates Resident R65 is cognitively intact. Level of Harm - Immediate jeopardy to resident health or Resident R65 is his own person. safety Resident R65's comprehensive care plan states, in part, as follows: Focus area: (Date Initiated: 11/4/24; Date Residents Affected - Some Revised: 3/9/25) The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) CVA (cerebrovascular accident); Goal: The resident will improve current level of function in ADL's (Activities of Daily Living) through the review date. Interventions: The resident requires hoyer transfer by (2) staff with bathing/showering 2 times a week and as necessary. Bed Mobility: The resident requires assist by (1) staff to turn and reposition in bed as necessary. Resident is able to reposition independently from side to side but needs reminders from staff and assistance at times. Contractures: Provide skin care to keep clean and prevent skin breakdown. Keep knee extended as much as resident can tolerate, no pain, while in bed. Use a pillow in between knees. Transfer: The resident requires dependent assist/hoyer by (2) staff to move between surfaces.

It is important to note, Resident R65 has a history of falls from bed.

On 2/11/25, Resident R65's Physician Orders document an air mattress was put in place.

On 3/11/2025 at 5:28 AM, Resident R65's Progress Notes document the following: Change of Condition (Res had fall from bed last night) Resident found down in room at 2:45 AM; no injuries noted and resident denies pain and injury. Per resident I slipped out of bed, help me get up. Resident assessed for injuries, neurological exam completed, and VS (vital signs) obtained. Resident assisted back to bed with the assist of two staff; care ongoing. Note, Resident R65's fall from bed puts him at increased risk of entrapment.

On 3/12/25 at 10:45 AM, Surveyor observed Resident R65 to have bilateral enabler bars with an air mattress. Surveyor observed a gap in between mattress and enabler bars of approximately one (1) inch.

On 3/12/25 at 11:00 AM, Surveyor spoke with Resident R65. Resident R65 stated his air mattress was put in place just a couple of days ago when he returned from the hospital on 3/7/25. Surveyor asked Resident R65, did the facility go over a consent form with you regarding using enabler bars with an air mattress. Resident R65 stated, no. Surveyor asked Resident R65, did the facility discuss the risks and benefits of using enabler bars with an air mattress. Resident R65 stated, no. Surveyor asked Resident R65, did the facility attempt alternatives prior to installing the bilateral enabler bars. Resident R65 stated, no. Surveyor asked Resident R65, have you ever become stuck (entrapped) in between an enabler bar and mattress. Resident R65 stated, no.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 40 525074 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525074 B. Wing 03/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Madison Health and Rehabilitation Center 110 Belmont Rd Madison, WI 53714

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 On 3/12/25 at 1:30 PM, Surveyor spoke with MD Q (Maintenance Director). Surveyor asked MD Q if he has done any assessments for Resident R65's air mattress being used with bilateral enabler bars. MD Q stated, no. MD Q Level of Harm - Immediate stated, if assessments are done he takes a couple measurements. MD Q added, he measures from the jeopardy to resident health or bottom of the mattress to the bottom of the siderail and the inside top of the mattress to the siderail with the safety resident in bed. MD Q stated this is a new process started 3/7/25. Surveyor asked MD Q, when was Resident R65's air mattress put in place. MD Q stated, he knows the facility swapped his air mattress to a larger size. MD Q Residents Affected - Some stated, Resident R65 had a 36 or 38 air mattress and now he has a 42 mattress that was put in place a few days ago. MD Q stated, Resident R65 had an air mattress in place prior to 3/7/25. MD Q stated he was going to check for the original work order. Surveyor asked Maintenance Q if he has measured gaps between the air mattress and enabler bars. MD Q stated, no. Surveyor asked MD Q, when you measure what are looking for? MD Q stated, pinch points or large enough gaps. Surveyor asked MD Q, what size of a gap is acceptable. MD Q stated, he's not sure and will look it up. MD Q stated, the Transfer Bar use Assessment Form was just started on 3/7/25. MD Q stated, there's no Transfer Bar use Assessment for Resident R65. Surveyor asked MD Q, what's the process started 5/7/25. MD Q stated, stated, he uses a tape measure to measure gaps. Note, no additional information was provided to Surveyor.

On 3/12/25 at 2:00 PM, Surveyor spoke with PTA R (Physical Therapy Assistant). Surveyor asked PTA R, have other alternatives been attempted prior to installing the air mattress with bilateral enabler bars. PTA R stated, no. Surveyor asked PTA R, does Resident R65 require assistance to turn and reposition in bed. PTA R stated, yes. PTA R stated, Resident R65 can use an enabler bar to assist staff with turning and repositioning, however, he does need assistance with turning and repositioning. PTA R added, Resident R65 uses the bilateral enabler bars to help staff, we want to encourage as much help as the residents can give to keep up their muscles and strength. Surveyor asked PTA R, given Resident R65's bilateral knee contractures and falls from bed would you consider him at high risk for entrapment. PTA R stated, she has not seen him in a little bit. PTA R added, Resident R65 had good movement with his upper body and arms, however, he doesn't tolerate any stretching at all, it's very painful for him. PTA R stated. she is unable to answer that question. PTA R stated, the facility just started a new process for assessing residents with air mattresses and side rails/enabler bars on 3/7/25. PTA R stated, she has not done any assessments for Resident R65.

It is important to note, there is no documentation for Resident R65 of risks and benefits, alternatives tried, measurements, assessments, or signed consents for the use of side rails. Resident R65 stated she had never signed any consent to use enabler bars with an air mattress, educated regarding the risk and benefits and alternatives attempted.

36253

Example 4

Resident R25 was admitted to the facility on [DATE REDACTED]. On 3/5/25 at 11:21 AM, Surveyor observed Resident R25 in her bed. She was lying on an air mattress with attached circulating pump and partial bedrails on either side of the bed. Facility maintenance documentation shows this air mattress was put into place on 2/18/25.

Surveyor attempted to interview Resident R25, but she was unable to answer any questions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 40 525074 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525074 B. Wing 03/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Madison Health and Rehabilitation Center 110 Belmont Rd Madison, WI 53714

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 A progress note dated 3/7/25 at 4:38 PM states, IDT (Interdisciplinary Team) review of resident need for t-bars per facility policy. Bars removed from resident bed and resident provided with education on safety/risk Level of Harm - Immediate of use of t-bars. jeopardy to resident health or safety It should be noted that Resident R25 discharged from the facility to the hospital on 3/6/25.

Residents Affected - Some On 3/12/25 at 1:00 PM, Surveyor requested any evaluations, assessments and risks and benefits for Resident R25 and the use of the partial side rails before 3/5/24 when Surveyors were in the facility. The facility was unable to provide this requested documentation.

42038

Example 5

Resident R17 was admitted to the facility on [DATE REDACTED] with diagnoses that include malignant neoplasm of anus, type 2 diabetes mellitus, and neuropathy.

Resident R17's MDS dated [DATE REDACTED], section O states that Resident R17 is on hospice care. Resident R17's MDS states that Resident R17 has a BIMS of 13 out of 15, indicating that Resident R17 is cognitively intact. Resident R17's MDS also states that he requires 1 assist to turn and reposition in bed.

On 3/12/25 at 1:46 PM, Surveyor interviewed Resident R17 and noted that Resident R17 has 1/4 side rails to each side of his bed and is on an air mattress. Surveyor asked Resident R17 if he uses the side rails on his bed, Resident R17 reported that he brought the right one from home and uses it to help himself sit on the edge of the bed. Resident R17 reported that he doesn't like the left one because it moves too much, but he uses it when he rolls on his side. Surveyor asked Resident R17 if facility staff discussed the risks and benefits of using side rails with him, Resident R17 reported that they had talked to him recently. Surveyor asked if he had given consent for the side rails, Resident R17 stated that he did last week.

It is important to note that Resident R17's Transfer Bar/ Mattress Safety Assessment, Transfer Bar Use Assessment Form, and Transfer Bar Informed Consent for Use were completed on 3/7/25.

Example 6

Resident R2 was admitted to the facility on [DATE REDACTED] with diagnoses that include spastic diplegic cerebral palsy (neurological disorder that affects movement and causes overly toned muscles), rheumatoid arthritis, neuropathy (nerve damage that usually occurs in feet and hands), and paraplegia (loss of motor and sensory function of the lower half of the body).

Resident R2's most recent MDS dated [DATE REDACTED] states that Resident R2 has a BIMS of 14 out of 15, indicating the Resident R2 is cognitively intact. The MDS states that Resident R2 requires substantial/ maximal assistance for bed mobility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 40 525074 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525074 B. Wing 03/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Madison Health and Rehabilitation Center 110 Belmont Rd Madison, WI 53714

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 On 3/12/25 at 1:50PM, Surveyor interviewed Resident R2. Surveyor noted that Resident R2 is laying on an air mattress and has enabler bars. Surveyor asked Resident R2 how long she has had the enabler bars, Resident R2 stated that she wasn't sure. Resident R2 Level of Harm - Immediate reported that it is hard for her to turn in bed without them. Resident R2 reported to Surveyor that they took one of the jeopardy to resident health or rails off and that the nurse agreed with her that she needed both rails. Surveyor asked Resident R2 if the facility she safety was assessed for the use of the bed rails, Resident R2 stated that she was last week. Surveyor asked if the facility discussed the risks and benefits of using the rails with her, Resident R2 reported that they did last week. Surveyor Residents Affected - Some asked if she gave consent for the rails, Resident R2 stated yes, last week.

It is important to note that Resident R2's Transfer Bar/ Mattress Safety Assessment, Transfer Bar Use Assessment Form, and Transfer Bar Informed Consent for Use were completed on 3/7/25.

49434

Example 7

Resident R423 was admitted to the facility on [DATE REDACTED] with diagnoses that include, in part: cerebrovascular accident (stroke), nontraumatic chronic subdural hemorrhage (brain bleed between the brain and the outer layer of the membrane around the brain), and dementia.

Resident R423's Admission Minimum Data Set, with Assessment Reference Date of 2/19/25, states that Resident R423 has a Brief Interview for Mental Status (BIMS) of 7 out of 15, indicating that Resident R423 is severely cognitively impaired. Section GG states Resident R423 has impairment on one side of her upper extremities and utilizes a walker and wheelchair for mobility. GG0170 indicates Resident R423 is dependent (meaning helper does all the effort) on staff for all mobility including rolling left and right, moving from sitting to lying and lying to sitting, moving from siting to standing, transferring between the bed and a chair, transferring to a toilet, transferring to a tub or shower, and walking 10 feet.

Resident R423's Comprehensive Care Plan states, in part: . The resident has an interpretation need . Resident's preferred language is: Hmong .The resident is at risk for falls, accidents and incidents r/t (related to) CVA[sic], Dementia, and Alzheimer's . Language board provided to the resident to facilitate communication . Nursing to keep resident within sight during time resident is in W/C (wheelchair) if CNA (Certified Nursing Assistant) is busy . Room change to facilitate closer observation . SS (Social Services) to conference with family concerning resident specific preferences r/t (related to) sitting on the floor, sleeping on the floor, environment .

A progress note, dated 3/1/25, indicates the Resident R423 was found sitting on the floor with blankets wrapped around her and the resident had been trying to get out of bed several times.

A progress note, dated 3/1/25 at 5:43 PM, indicates Resident R423 continues to have neurological checks completed related to her recent unwitnessed fall. The note also indicates the resident continues to self-transfer on this shift and had been found getting up from her wheelchair and attempting to ambulate.

A progress note, dated 3/2/25 at 11:34 PM, indicates Resident R423 continues to have neurological checks completed related to her unwitnessed fall. The note also indicates Resident R423 was experiencing agitation on the PM shift and was given PRN (as needed) Haldol (antipsychotic). However, Resident R423 continued to be restless, attempting self-transfers, and the facility initiated 1 to 1 monitoring on this shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 40 525074 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525074 B. Wing 03/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Madison Health and Rehabilitation Center 110 Belmont Rd Madison, WI 53714

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 A progress note, dated 3/3/25 at 9:57 PM, indicates Resident R423 continues on neurological checks related to her recent fall and that the resident remains on 1 to 1 monitoring on this shift due to impulsivity and her attempts Level of Harm - Immediate to transfer independently. jeopardy to resident health or safety On 3/5/25 at 10:15 AM, Surveyor observed Resident R423 lying in her bed. Resident R423's bed was in the low position with a floor mat on the floor. Surveyor noted that Resident R423 had an air mattress on her bed with grab bars installed on Residents Affected - Some both sides.

On 3/5/25 at 3:10 PM, Surveyor observed Resident R423's bed with the air mattress and grab bars still in place.

On 3/10/25 at 4:20 PM, Surveyor observed Resident R423's bed had an air mattress installed with dial set to 120 and grab bars attached.

On 3/12/25 at 10:30 AM, Surveyor observed Resident R423's bed still had the air mattress on her bed with the grab bars installed. Surveyor notes the gap between the mattress and the grab bar is large enough for the Surveyor to fit their arm in between the mattress and the grab bar.

(Of note: No evidence was found, and no evidence could be provided regarding a bed rail evaluation for Resident R423. Surveyor also found no evidence of risks and benefits being provided to Resident R423's activated healthcare power of attorney or evidence that alternatives to the grab bars were attempted prior to their installation).

Example 8

Resident R424 was admitted on [DATE REDACTED] with diagnoses that include, in part: acute infarction of the spinal cord (stoke occurring within the spinal cord instead of the brain), transient ischemic attack (stroke that completely resolves within 24 hours), and quadriplegia (from of paralysis affecting all four limbs and torso).

Resident R424's Admission Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 2/19/25, states that Resident R424 has a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating that Resident R424 is cognitively intact. Section GG states Resident R424 has impairment in both of her upper extremities and one side of her lower extremities along with an electric wheelchair for mobility. GG0170 indicates Resident R424 requires partial/moderate assistance with rolling left and right. GG0170 also indicates Resident R424 is dependent (meaning helper does all the effort) on staff for most mobility including moving from sitting to lying and lying to sitting, moving from siting to standing, transferring between the bed and a chair, transferring to a toilet, and transferring to a tub or shower.

On 3/12/25, Surveyor was provided with a document titled, Transfer Bar Use Assessment Form. This form indicates Resident R424 requested a transfer bar for safety and for mobility/transferring assistance. Potential risks and benefits are indicated to be discussed with the resident along with the completion of a mobility transfer assessment. Therapy evaluation is indicated to be conducted by physical therapy. Transfer bars are indicated to be recommended for the left and right side of Resident R424's bed. PTA R signed this form on 3/7/25.

(Of note: This form does note make any statements or references to safety in regard to using a transfer bar with an air mattress).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 40 525074 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525074 B. Wing 03/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Madison Health and Rehabilitation Center 110 Belmont Rd Madison, WI 53714

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 On 3/12/25, Surveyor was provided with a document titled, Transfer Bar Informed Consent for Use. This document states, in part: .It is the policy of this facility to use transfer bar only after an individualized resident Level of Harm - Immediate assessment evaluation and care planning by an interdisciplinary team, determine it is beneficial and jeopardy to resident health or appropriate for use to treat the resident's medical symptoms, assist the resident in attaining or maintaining safety the highest possible physical and psychosocial wellbeing and after attempts of using alternatives have proven inadequate or inappropriate . One question asked on this form states: Alternatives attempted that Residents Affected - Some failed to meet resident needs: is marked n/a. Another question asked on this form states: Alternatives considered but not attempted because they were considered inappropriate: is marked lack of transfer bars.

This document indicates recommendation of left and right transfer bars with Resident R424's initials and signatures indicating they voluntarily consent to the use of transfer bars and is dated 3/7/25. This documented is signed by PTA R on 3/7/25.

(Of note: This form does note make any statements or references to safety in regard to using a transfer bar with an air mattress).

On 3/12/25, Surveyor was provided with a document titled, Transfer Bar/Mattress Safety Assessment. Resident R424'S name and room number are indicated at the top of the assessment; however, the date of assessment, resident height, and resident weight is blank. The section that states, Reason for Assessment: has nothing checked. The section titled, Device Information includes the following information, type of bed: Standard, type of mattress: Air Mattress, and type of device: Transfer bar. The section titled, Gap Assessment, states, in part: The gap between the mattress and the lowermost portion of the bed rail can be no greater than 2.5 inches or 1.75 for this resident. The gap between the inside surface of the bed rails and

the mattress can be no greater than 4.5 inches or 3 1/8 for this resident . Each zone listed in this section is marked, Pass. The section titled, General Safety Assessment has not been completed. The signature line states, Signature and Title, which is signed but illegible and it appears that no title was provided. This document is dated 3/7/25.

50285

Example 9

Resident R6 was admitted to the facility on [DATE REDACTED] with diagnoses that include, in part, Alzheimer's disease, age related osteoporosis with current pathological fracture, unspecified dementia with agitation, depression, and adult failure to thrive. Resident R6's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 1/17/25, indicates Resident R6 has a Brief Interview for Mental Status (BIMS) score of 5 indicating Resident R6 is severely cognitively impaired. Resident R6 has an activated power of attorney.

Resident R6's Comprehensive Care Plan, states, in part; .Bed Mobility: The resident requires partial assistance by 1 staff to turn and reposition in bed as necessary . 1 assist, uses bilateral hand rails to improve independence. 2 assist prn . Transfer: The resident requires max assistance of 1 to move between surfaces at a stand pivot level. Resident R6 was assessed on 11/16/24 as a moderate risk for falls.

On 3/5/25 at 3:55 PM, Surveyor observed Resident R6 lying in bed. Resident R6 was observed to have an air mattress with side rails. It is important to note, there is no documentation for Resident R6 of risks and benefits, alternatives tried, measurements, assessments, or signed consents for the use of side rails.

On 3/11/25 at 8:04 AM, DON B indicated Resident R6 does not have any assessments or documentation for side rails because Resident R6 no longer has side rails. DON B indicated Resident R6's side rails were taken off on 3/7/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 40 525074 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525074 B. Wing 03/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Madison Health and Rehabilitation Center 110 Belmont Rd Madison, WI 53714

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0700 On 3/13/25 at 11:24 AM, Surveyor interviewed POA EE (Power of Attorney). POA EE stated she had never signed a consent or been provided education on the risks and benefits of the use of side rails. Level of Harm - Immediate jeopardy to resident health or Example 10 safety Resident R24 was admitted to the facility on [DATE REDACTED] with diagnoses that include, in part, Type 2 diabetes mellitus, Residents Affected - Some depression, dependence on renal dialysis, acquired absence of left leg below knee, end stage renal disease, and insomnia. Resident R24's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 2/2/25 indicates Resident R24 has a BIMS (Brief Interview for Mental Status) score of 15 indicating Resident R24 is cognitively intact. Resident R24 is her own person.

Resident R24's Comprehensive Care Plan, states, in part: Bed Mobility: The resident requires assistance by 2 staff to turn and reposition in bed . Transfer: The resident is dependent upon staff assist of 2 and Hoyer lift . Skin integrity: Pressure redistribution mattress. Resident R24 was assessed on 1/13/25 as a moderate risk for falls.

On 3/5/25 at 10:31 AM,

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 40 525074