Belmont Nursing And Rehab Ctr

F-F686.

Example 4:

The Facility Assessment indicates the ability to provide infection prevention and control services.

Several breaches in infection control were observed by Surveyors. The Infection Preventionist failed to recognize and control an ESBL outbreak on one unit. Resident R223 had extended-spectrum beta-lactamase (ESBL),

a multi-drug-resistant organism (MDRO) in Resident R223's urine. ESBL is spread easily through hands and surfaces.

The facility failed to ensure Resident R223 was placed in proper transmission-based precautions. Resident R32, Resident R44, and Resident R47 also tested positive after Resident R223 was diagnosed with ESBL. Three of the residents resided on the same hall.

Facility had no evidence precautions were put into place for Resident R223, Resident R32, Resident R44, and Resident R47 with confirmed ESBL.

Staff did not complete hand hygiene according to Standards of Practice during cares for Resident R25 and Resident R74.

Staff did not handle soiled linens appropriately. During Resident R74's bed bath, staff threw dirty, soiled clothing and linens on the floor.

Staff did not complete hand hygiene for residents prior to eating.

Facility did not provide evidence the infection control policies get reviewed annually.

These multiple areas of deficient practices indicate the staff did not have the appropriate skills and competencies required for infection prevention and control.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 80 of 97 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 0838 Cross-reference

F-F698.

Example 3:

The Facility Assessment indicates the ability to care for residents with pressure injuries. However, two residents were found to have advanced stage pressure injuries.

Resident R25 was at risk for developing pressure injuries related to immobility and history of poor nutrition. The facility failed to implement aggressive pressure injury interventions; failed to implement orders timely; failed to provide risks and benefits despite knowledge of Resident R25 refusing repositioning. Resident R25's treatment was observed by surveyors to not be in accordance with physician orders and the facility staff did not wear the appropriate Personal Protective Equipment (PPE). Resident R25 developed an in-house unstageable pressure injury on her sacrum on 2/8/25 and required transfer to the hospital on 3/6/25 where Resident R25's sacrum wound was assessed as a stage IV and found to be infected.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 79 of 97 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 0838 Resident R65 was at risk for pressure injury (PI) development. On 3/3/25 during a routine visit, NP C (Nurse Practitioner) discovered Resident R65 had an Unstageable PI to the right lateral heel. The facility staff did not Level of Harm - Minimal harm or implement appropriate offloading interventions until after the PI was discovered. Despite facility staff applying potential for actual harm skin prep to the PI twice daily, nursing staff did not identify the Unstageable PI, assess and measure the PI, and notify the provider. Resident R65 stated staff were not turning and repositioning him every 2 hours and have not Residents Affected - Many provided risks and benefits regarding not repositioning at least every 2 hours. Surveyor observed Resident R65's PI uncovered and open to air. CNA G (Certified Nursing Assistant) stated she noted Resident R65's dressing was off approximately 1.5 hours prior to Surveyor's observation and did not notify the nurse.

The facility staff failed to implement appropriate interventions based on the comprehensive assessment of a resident and failed to demonstrate the skills and competencies necessary to ensure residents receive care, consistent with professional standards of practice, to prevent pressure injuries and does not develop pressure injuries unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure injuries receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing or worsening.

Cross-reference

F-F700.

The facility assessment did not accurately reflect the resident population or the resources needed to care for

the residents residing within the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 81 of 97 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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41788

Residents Affected - Few Based on interview and record review, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. Resident R223 had a multi-drug resistant organism (MDRO) in her urine. Resident R32, Resident R44, and Resident R47 later tested postived for the same MDRO. Hand hygiene was not performed per standards of practice for (Resident R25 and Resident R74). Residents (Resident R223, Resident R32, Resident R44, & Resident R47) are being cited at severity level 3 (actual harm), and (Resident R25 and Resident R74) are being cited at severity level 2 (potential for more than minimal harm).

Resident R223 had extended-spectrum beta-lactamase (ESBL) a MDRO, in Resident R223's urine. ESBL is spread easily through hands and surfaces. The facility failed to ensure Resident R223 was placed in proper transmission-based precautions. Resident R32, Resident R44, & Resident R47 also tested positive after Resident R223 was diagnosed with ESBL. Three of the residents resided on the same hall.

Facility had no evidence precautions were put into place for Resident R223, Resident R32, Resident R44, & Resident R47 with confirmed ESBL.

Staff did not complete hand hygiene according to Standards of Practice during cares for Resident R25 & Resident R74.

Staff did not handle soiled linens appropriately. During Resident R74's bed bath, staff threw dirty, soiled clothing and linens on the floor.

Staff did not complete hand hygiene for residents prior to eating.

Facility did not provide evidence the infection control policies get reviewed annually.

This is evidenced by:

The facility policy titled, Infection Prevention and Control Program, dated 10/4/23, states in part:

POLICY: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines .

Policy Explanation and Compliance Guidelines:

1. The designated Infection Preventionist is responsible for oversight of the program and serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases .

3. Surveillance:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 82 of 97 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 0880 a. A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals Level of Harm - Actual harm providing services under a contractual arrangement based upon a facility assessment and accepted national standards. Residents Affected - Few b. The Infection Preventionist serves as a leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility .

4. Standard Precautions: .

b. Hand hygiene shall be performed in accordance with our facility's established hand hygiene procedures.

c. All staff shall use personal protective equipment (PPE) according to established facility policy governing

the use of PPE .

5. Isolation Protocol (Transmission- Based Precautions):

a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC (Centers for Disease Control) guidelines.

b. Residents on transmission-based precautions should be placed into a private/single room if available/appropriate, or are cohorted with residents with the same pathogen, or share a room with a roommate with limited risk factors, in accordance with national standards .

12. Linens:

a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection .

e. Soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room .

16. Staff Education:

a. All staff receive training, relevant to their specific roles and responsibilities, regarding the facility's infection prevention and control program, including policies and procedures related to their job function.

b. All staff shall demonstrate competence in relevant infection control practices .

18. Annual Review:

a. The facility will conduct an annual review of the infection prevention and control program, including associated programs and policies and procedures .

The facility policy titled, Infection Outbreak Response and Investigation, dated 12/23/22, states, in part: .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 83 of 97 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 0880 Policy: The facility promptly responds to outbreaks of infectious diseases within the facility to stop transmission of pathogens and prevent additional infections. Level of Harm - Actual harm Definitions: Outbreak generally refers to the occurrence of more cases of a communicable disease than Residents Affected - Few expected in a given area or among a specific group of people over a particular period of time .

Policy Explanation and Compliance Guidelines:

1. Prompt recognition of outbreak:

a. Changes in condition and/or signs and symptoms of infection will be reported according to procedures for infection reporting.

b. The following triggers shall prompt an investigation as to whether an outbreak exist: .

ii. A sudden cluster of infections on a unit or during a short period of time (i.e. three or more cases) .

2. Implementation of infection control measures: .

c. Standard precautions will be emphasized. Transmission-based precautions will be implemented as indicated for the particular organism.

d. Staff will be educated on the mode of transmission of the organism, symptoms of infection, and isolation or other special procedures. This includes special environmental infection control measures that are warranted based on the organism and current CDC guidelines .

The facility policy titled, Handwashing/Hand Hygiene, dated 9/21, states, in part: .

Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections.

Policy Interpretation and Implementation:

1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing

the transmission of healthcare-associated infections.

2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .

7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .

c. Before and after direct contact with residents; .

e. Before performing any non-surgical invasive procedures; .

h. Before handling clean or soiled dressings, gauze pads, etc.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 84 of 97 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 0880 i. Before moving from a contaminated body site to a clean body site during resident care;

Level of Harm - Actual harm j. After contact with a resident's intact skin;

Residents Affected - Few k. After contact with blood or bodily fluids;

l. After handling used dressings, contaminated equipment, etc.;

m. After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident;

n. After removing gloves; .

9. The use of gloves does not replace hand washing/hand hygiene .

According to <https://www.cdc.gov/esbl-producing-enterobacterales/about/index.html> Extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales are resistant to common antibiotics and may require complex treatments. Infections caused by ESBL-producing Enterobacterales can occur both in and outside of healthcare settings. Good hand hygiene and infection prevention practices can help reduce infection risk. Enterobacterales are a group of bacteria that cause infections in healthcare settings and communities. Some species are also a normal part of the human gut. Some Enterobacterales produce enzymes called extended-spectrum beta-lactamases (ESBLs). Extended-spectrum beta-lactamases (ESBLs) break down certain antibiotics, making some infections caused by ESBL-producing Enterobacterales difficult to treat. ESBL-producing Enterobacterales infections occur in healthcare settings like hospitals and nursing homes.

These infections may also occur in healthy people. ESBL-producing Enterobacterales can spread from person to person through dirty hands and surfaces. Reducing the risk healthcare workers should: Wash their hands often with soap and water or using alcohol-based hand sanitizer. Wash their hands after using the bathroom and before eating or preparing food. Remind people (including healthcare staff) to clean their hands before touching the patient or handling medical devices. Healthcare providers should always follow core infection control practices to reduce the risk of spreading these germs to patients. Treatment and recovery: ESBL-producing Enterobacterales infections are resistant to many prescribed antibiotics, such as penicillin's and cephalosporins. These infections might require hospitalization and intravenous (IV) antibiotics.

According to <https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html> Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) How to implement personal protective equipment (PPE) use in nursing homes to prevent spread of multi-drug resistant organisms (MDROs). Multidrug-resistant organism (MDRO) transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status; infection or colonization with an MDRO.

Effective implementation of EBP requires staff training on the proper use of personal protective equipment (PPE) and the availability of PPE and hand hygiene supplies at the point of care. Standard Precautions, which are a group of infection prevention practices, continue to apply to the care of all residents, regardless of suspected or confirmed infection or colonization status.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 85 of 97 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 0880 Example 1

Level of Harm - Actual harm Resident R223 admitted to the facility on [DATE REDACTED] and has diagnoses that include chronic kidney disease stage 3 (kidneys have mild to moderate damage, meaning they're less effective at filtering waste and fluid from your Residents Affected - Few blood) and malignant neoplasm (cancerous tumor) of right kidney.

Resident R223 had a urinalysis (UA) and culture and sensitivity (C&S) on 1/1/25, which showed Resident R223 was positive for

a urinary tract infection (UTI). Resident R223's culture showed 1) Escherichia coli (bacteria that causes UTIs) >100, 000 COL/ML (colony forming units in milliliter of urine) and 2) Proteus mirabilis ESBL (Gram negative bacterium that causes variety of infections including UTIs.) (ESBL-extended-spectrum beta-lactamase- an enzyme produced by certain bacteria that makes them resistant to many commonly used antibiotics, making

it harder to treat) producing Proteus mirabilis are resistant to several antibiotics) >10,000- 50,000 COL/ML.

Result phoned, read back, and faxed/electronically transmitted . Positive for ESBL. This organism is an extended-spectrum beta-lactamase producer. These organisms may not clinically respond to treatment with cephalosporins, extended-spectrum penicillin or aztreonam. Isolation precautions may be required.

Facility's surveillance list for residents for month of January 2025 shows:

Resident R223- Onset Date- 1/11/25. Site- GU (GENITOURINARY) SYSTEM. Symptoms- trouble urinating and burning. Diagnostics/Results- UTI. Type of isolation- N/A (NOT APPLICABLE). Treatment & Intervention- Ceftriaxone Sodium Injection solution reconstituted 1 gram. HAI (healthcare acquired infection) /CAI (community acquired infection)- HAI. Completion Well Date- 1/14/25.

*Note: Per CDC guidelines Enhanced Barrier Precautions (use of gloves and gown during high contact resident care) recommended.

Example 2

Resident R32 admitted to the facility on [DATE REDACTED] and has diagnoses that include chronic kidney disease stage 3 and metabolic encephalopathy (a condition where the brain's function is impaired due to an underlying metabolic disturbance).

Resident R32 had a UA and C&S on 2/3/25, which showed Resident R32 was positive for a UTI. Resident R32's urine culture showed 1) Citrobacter freundii complex-ESBL (gram negative bacteria that can cause various infections, including a UTI). 50,000-100,000 COL/ML. Positive for ESBL. This organism is an extended-spectrum beta-lactamase producer. These organisms may not clinically respond to treatment with cephalosporins, extended-spectrum penicillin or aztreonam. Isolation precautions may be required. 2) Enterococcus faecium (a gram-negative bacterium, is resistant to many standard therapies, including antibiotics) -10,000-50,000 COL/ML.

Facility's surveillance list for residents for month of February 2025 shows:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 86 of 97 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 0880 Resident R32 (100 hallway)- Onset Date- 2/5/25. Site- GU. Symptoms- Multiple organisms noted in UA: ESBL (50, 000- 100,000) and Enterococcus faecium (10,000-50,000COL/ML) Burning with urination, public tenderness, Level of Harm - Actual harm foul smelling urine, darkened discolored urine. Diagnostics/Results- UTI. Type of isolation- N/A. Treatment & Intervention- Macrobid Oral Capsule 100mg (milligrams). HAI/CAI- HAI. Completion Well Date- 2/9/25. Residents Affected - Few *Note: Per CDC guidelines Enhanced Barrier Precautions (use of gloves and gown during high contact resident care) recommended.

Example 3

Resident R44 admitted to the facility on [DATE REDACTED] and has diagnoses that include neuromuscular dysfunction of bladder (a condition where bladder control is lost due to damage to the nerves resulting in difficulties with urination) and hemiplegia (severe weakness/complete paralysis on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction affecting left dominant side.

Resident R44 had an UA and C&S on 2/18/24, which showed Resident R44 was positive for a UTI. Resident R44's urine culture showed Proteus vulgaris-ESBL (a rod-shaped, gram-negative bacterium that can cause urinary tract and wound infections) 50,000-100,000 COL/ML. Positive for ESBL. This organism is an extended-spectrum beta-lactamase producer. These organisms may not clinically respond to treatment with cephalosporins, extended-spectrum penicillin or aztreonam. Isolation precautions may be required. Please refer to your infection control policy. Result phoned, read back, and faxed/electronically transmitted to .

Facility's surveillance list for residents for month of February 2025 shows:

Resident R44 (Hallway 100)- Onset Date- 2/20/25. Site- GU. Symptoms- ESBL Culture results= 50,000 through 100, 000 col/ml. NP (Nurse Practitioner) informed-wants to keep medication active for resident. Diagnostics/Results- UTI. Type of isolation- N/A. Treatment & Intervention- Cefpodoxime Proxetil Oral Tablet 100 mg. HAI/CAI- HAI. Completion Well Date-2/27/25.

*Note: Per CDC guidelines Enhanced Barrier Precautions (use of gloves and gown during high contact resident care) recommended.

Example 4

Resident R47 was admitted to the facility on [DATE REDACTED] and has diagnoses that include end stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids) and dependence on renal dialysis (a medical procedure that removes waste products and excess fluid from the blood when the kidneys are unable to do so).

Resident R47 had an UA and C&S on 2/17/25 that showed Resident R47 was positive for an UTI. Resident R47's urine culture showed Klebsiella oxytoca-ESBL (a gram-negative, rod-shaped bacteria that can cause a range of infections, from mild diarrhea to life-threatening bacteremia and meningitis). Positive for ESBL. This organism is an extended-spectrum beta-lactamase producer. These organisms may not clinically respond to treatment with cephalosporins< extended-spectrum penicillin or aztreonam. Isolation precautions may be required. Please refer to your infection control policy. Result phoned, read back, and faxed/electronically transmitted to .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 87 of 97 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 0880 Facility's surveillance list for residents for month of February 2025 shows:

Level of Harm - Actual harm Resident R47 (Hallway 100)- Onset Date- 2/22/25. Site- GU. Symptoms- Klebsiella Oxytoca 50,000=100,000 COL/ML (Positive for ESBL). Confusion, pubic pain. Diagnostics/Results- ESBL-UTI. Type of isolation- N/A. Residents Affected - Few Treatment & Intervention- Cipro Oral Tablet 500 mg. Give after dialysis. HAI/CAI- HAI. Completion Well Date- 2/27/25.

*Note: Per CDC guidelines Enhanced Barrier Precautions (use of gloves and gown during high contact resident care) recommended.

On 3/10/25 at 10:01 AM, Surveyor interviewed CNA Y (Certified Nursing Assistant) and asked if CNA Y had received any education on PPE, handwashing, and precautions. CNA Y indicated staff received education on handwashing and PPE for norovirus outbreak. Surveyor asked if CNA Y was aware of any residents with MDRO's and what care requirements would include for these residents. CNA Y stated she was not aware of residents with MDROs or what precautions would be required for these residents.

On 3/10/25 at 10:14 AM, Surveyor interviewed CNA Z who indicated education on PPE and handwashing was received only in orientation. Surveyor asked if CNA Z was aware of any residents with MDRO's and what care requirements would include for these residents. CNA Z stated she was not aware of residents with MDROs or what precautions would be required for these residents.

On 3/10/25 at 10:20 AM, Surveyor interviewed LPN AA (Licensed Practical Nurse) who indicated education

on PPE may have been a few months back, but she could not remember. Surveyor asked LPN AA if she was aware of residents on MDRO's LPN AA stated she was not aware of residents with MDROs, LPN AA stated

a resident with an MDRO would require transmission-based precautions.

On 3/11/25 at 12:02 PM, Surveyor interviewed IP D (Infection Preventionist) regarding Resident R223's ESBL infection. Surveyor asked IP D when the facility received Resident R223's lab results indicating Resident R223 had ESBL in the urine what did facility do? IP D indicated MDRO Precautions would have been put into place for Resident R223. Surveyor showed IP D the facility line list under type of isolation the line list indicates isolation precautions were documented as N/A. IP D indicated he does not know why he put N/A in there, he thought he had put precautions into place but can't remember for sure. Surveyor asked if any staff training was provided at that time. IP D indicated staff get trained at orientation on PPE (Protective Personal Equipment), hand washing and on peri cares. IP D indicated precaution signs would be placed as needed and if staff have any questions they are to come to me. Surveyor asked if there are any other times staff should receive education

on infection prevention and IP D indicated if there were concerns with infection control and if failure to use infection prevention measures. Surveyor asked IP D if any education would be provided to staff with an outbreak and IP D indicated yes, on what the outbreak was and the necessities for the outbreak. Surveyor asked what is meant by necessities and IP D indicated for COVID outbreak- the PPE and hand washing, and for GI (gastrointestinal) outbreak and respiratory would be same ballpark and to keep everyone as safe as possible. Surveyor asked about Resident R32, Resident R44, and Resident R47's lab results showing positive for ESBL. IP D referred Surveyor to DON B (Director of Nursing).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 88 of 97 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 0880 On 3/12/25 at 9:03 AM, Surveyor interviewed DON B. Surveyor requested March 2025 line list. DON B indicated she would get Surveyor a copy. Surveyor asked DON B regarding Resident R223's ESBL infection. Surveyor Level of Harm - Actual harm asked DON B when the facility received Resident R223's lab results indicating Resident R223 had ESBL in the urine what did facility do? DON B indicated she will have to get back to Surveyor. Surveyor asked DON B about Resident R32, Resident R44, Residents Affected - Few and Resident R47's positive ESBL, what precautions were put into place, what cleaning and disinfecting went into effect, and if education was provided to staff on hand washing, PPE, ESBL/precautions. DON B indicated

she will get back to Surveyor. Surveyor asked if poor hand hygiene or lack of PPE use could contribute to the spread of ESBL and DON B indicated yes.

On 3/12/25 at 5:44 PM, Surveyor interviewed DON B and asked if there were concerns after Resident R223 had an ESBL infection. DON B indicated yes this would be a concern. DON B indicated the facility tracks MDROs by line lists and mapping of symptoms. Surveyor asked DON B would you expect the positive cases of ESBL on

the 100 hallway within the month of February to be recognized as a concern. DON B indicated it should have been recognized. Surveyor asked DON B if she would expect education to be provided to staff on MDROs, hand hygiene and precautions to be put into place. DON B indicated yes, and she would have to check with

the educator to see if education was provided. DON B indicated it is a concern to have multiple cases of MDROs on the same hallway. The concern would be the spread to others and of course the concern of antibiotic resistance. Surveyor asked DON B would you expect the IP to follow outbreaks and DON B indicated yes.

On 3/12/25 at 5:56 PM, Surveyor interviewed IP D. IP D indicated he would expect education to be provided to staff regarding ESBL, hand washing, peri cares and PPE/precautions. IP D indicated having 4 positive cases of ESBL within a short period of time in the facility is concerning with possible spread of a MDRO. IP D indicated he would expect residents with ESBL to be on precautions and he cannot pinpoint if the Resident R223, Resident R32, Resident R44, & Resident R47 residents were put on precautions and if so what for. IP D indicated he has no documentation to show the residents were on precautions.

On 3/17/25 at 8:27 AM, Surveyor interviewed NP C (Nurse Practitioner) and asked NP C if she was aware of multiple cases of ESBL in the facility starting in January 2025 and in the month of February 2025. NP C indicated she would have to go back and look, at this time NP C indicated she does not know. Surveyor asked NP C if this were something she would want to be notified of and NP C indicated yes, if it were her patients. Surveyor asked NP C in her opinion how would this be a concern for the facility. NP C indicated

they would want to know why this is occurring and see if their infection control practices need to be changed. Surveyor asked NP C how she would expect the facility to address multiple cases of ESBL in the facility. NP C indicated by making sure with the cases of ESBL precautions are being met and review who has been taking care of those residents. I would expect the facility to follow the proper precautions which would include gown and gloves and the standard precautions for ESBL.

Example 5

Resident R25 admitted to the facility on [DATE REDACTED] and has diagnoses that include Diabetes Mellitus (a disease that result

in too much sugar in the blood).

Resident R25's Quarterly Minimum Data Set (MDS) Assessment, dated 2/4/25, shows Resident R25 has a Brief Interview of Mental Status (BIMS) score of 14 indicating Resident R25 is cognitively intact.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 89 of 97 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 0880 On 3/6/25 at 9:56 AM, Surveyor observed wound care on Resident R25 with CNA G (Certified Nursing Assistant) and RN F (Registered Nurse). It is important to note that Resident R25 is on EBP (Enhanced Barrier Precautions), Level of Harm - Actual harm requiring staff to wear gloves, gown, and mask while performing cares.

Residents Affected - Few RN F (Registered Nurse) and CNA G entered Resident R25's room without performing hand hygiene and without wearing a gown. RN F removed the old Mepilex dressing that was saturated with purulent and bloody drainage. RN F then cleansed the wound with wound cleanser. RN F changed her gloves and did not perform hand hygiene. RN F applied the Dakin's-soaked gauze, skin prep applied to peri- wound, Hydralock applied, and covered with a Mepilex.

RN F changed her gloves, but did not perform hand hygiene and began incontinence care, as Resident R25 was incontinent of stool. RN F changed her gloves, but did not perform hand hygiene and performed catheter care on Resident R25.

On 3/6/25 at 10:28 AM, Surveyor interviewed CNA G. Surveyor asked CNA G what type of PPE (Personal Protective Equipment) should be worn in a room that has EBP, CNA G reported that they should wear a gown, gloves, and a mask. Surveyor asked CNA G if she should have been wearing a gown during wound care, CNA G stated yes.

On 3/6/25 at 10:28 AM, Surveyor interviewed RN F. Surveyor asked RN F what PPE should be worn in a room with EBP, RN F stated gloves and mask, but that she wasn't sure about a gown. RN F and Surveyor reviewed the EBP sign on Resident R25's door. Surveyor asked RN F if she should have had a gown on, RN F stated yes. Surveyor asked RN F if she had any missed opportunities for hand hygiene, RN F stated yes, she should have performed hand hygiene before starting wound care. Surveyor asked RN F if she should have performed hand hygiene after taking off soiled gloves and before applying clean gloves, RN F stated yes.

Example 6

Resident R74 admitted to the facility on [DATE REDACTED] and has diagnoses that include cerebral infarction (also known as an ischemic stroke, a condition where blood flow to the brain is interrupted, causing brain cells to die) and unspecified symptoms and signs involving cognitive functions and awareness.

Resident R74's Quarterly MDS Assessment, dated 1/25/25, section C shows no BIMS score recorded, indicating Resident R74's cognitive status was not assessed or deemed not applicable during the assessment period.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 90 of 97 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 0880 On 3/11/25 at 9:42 AM, Surveyor observed CNA M give Resident R74 a bed bath. CNA M did not change gloves and perform hand hygiene after washing Resident R74's peri area and then reaching into clean rinse basin for wash cloth Level of Harm - Actual harm to rinse Resident R74's peri area. CNA M removed gloves during bed bath and reached into her pocket for her phone and accessed Google Translate to ask Resident R74 what she was saying without performing hand hygiene. CNA M Residents Affected - Few then applied new gloves without hand hygiene and continued with bed bath. CNA M threw a soiled brief and gown on Resident R74's floor along with the used washcloths and towels. CNA M kept same soiled gloves on and began dressing Resident R74. During this time, CNA M grabbed the bed remote, grabbed Resident R74's slippers out from under the bed, opened Resident R74's door and grabbed the EZ stand from out in the hallway, picked up the soiled brief, the gown and used washcloths from bed bath off the floor and threw to another area on the floor to get

the EZ stand up to the bed. CNA M then transferred Resident R74 into the wheelchair and adjusted Resident R74's clothing once in wheelchair with the same dirty gloves on. CNA M opened Resident R74's drawer and grabbed Resident R74's brush and ponytail holder and brushed Resident R74's hair and put her hair in a ponytail with same dirty gloves on. CNA M transferred Resident R74 halfway down the hallway and then stopped at a hand sanitizer mounted on wall, removed gloves and used hand sanitizer, then continued to take Resident R74 to lounge area.

On 3/11/25 at 10:16 AM, Surveyor interviewed CNA M and asked if there were missed hand hygiene opportunities during Resident R74's bed bath. CNA M indicated after peri care, when she went in and out of room, and

before taking Resident R74 down the hallway. CNA M indicated gloves and hand hygiene should have been done 4 to 5 times during bed bath but Resident R74 was rushing her. CNA M indicated hand hygiene should have been performed before brushing Resident R74's hair and before grabbing bed remote, EZ stand and wheelchair. Surveyor asked CNA M if it is appropriate to throw dirty laundry on the floor and CNA M indicated that is what they do here. CNA M indicated it is not appropriate, but the facility does not have bins in the rooms to place laundry in. Surveyor asked CNA M if she received any education on PPE, precautions or hand washing. CNA M indicated no.

On 3/12/25 at 9:03 AM, Surveyor interviewed DON B (Director of Nursing) and asked if dirty clothes, used wash clothes and towels and soiled briefs should be thrown on the floor while performing a bed bath. DON B indicated no. DON B indicated the facility has special containers the dirty clothes go in on each unit. Surveyor asked what staff should do with dirty clothing and linens etc. during care and DON B indicated staff should put dirty linens and clothing in a plastic bag. Surveyor informed DON B of observation of CNA M with missed hand hygiene opportunities during bed bath and dirty clothing and linens being thrown on Resident R74's floor. DON B indicated that is not appropriate. DON B indicated she would have expected hand hygiene any time gloves get changed, after peri cares, before leaving room, before handling bed remote, wheelchair, EZ stand and resident.

Example 7

The facility did not provide evidence the infection control policies get reviewed annually.

-Infection Outbreak Response and Investigation- dated 12/23/22.

-Management of Respiratory Syncytial Virus (RSV)- dated 12/1/22.

-COVID-19 Vaccination- 5/16/23.

-Influenza Vaccination- 8/30/23.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 91 of 97 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 0880 -Pneumococcal Vaccine- 8/30/23.

Level of Harm - Actual harm -Antibiotic Stewardship Program- 10/4/23.

Residents Affected - Few -Infection Control Surveillance-10/4/23.

-Hand washing- 9/21.

Surveyor asked IP D and DON B for evidence polices were reviewed annually. No evidence was brought to Surveyor.

On 3/10/25 at 1:30 PM, Surveyor interviewed IP D and asked how often Infection Control Policies are to be reviewed. IP D indicated the DON B and NHA A (Nursing Home Administrator) review them yearly. Surveyor asked IP D if there is evidence of this and IP D indicated he would have to check with DON B.

On 3/12/25 at 9:03 AM, Surveyor asked DON B if there were evidence the Infection Control Policies were reviewed annually. DON B indicated she would see if there were a sheet signed for annual review.

50285

Example 8

On 3/6/25 at 8:04 AM, Surveyor observed CNA GG (Certified Nursing Assistant) passing hall trays on [NAME] Hallway. No hand hygiene was being offered to residents before eating.

On 3/6/25 at 9:18 AM, Surveyor interviewed CNA GG and asked when it was appropriate to complete hand hygiene. CNA GG stated that she performs hand hygiene before and after completing cares with the resident. Surveyor asked CNA GG if hand hygiene should be offered to the residents before eating. CNA GG stated yes. Surveyor asked CNA GG if she had offered the residents hand hygiene before she gave them their meal trays. CNA GG stated that she had not because there was no hand sanitizer available.

Example 9

On 3/11/25 at 7:40 AM, Surveyor observed CNA M passing hall trays on [NAME] Hallway. No hand hygiene was being offered to residents before eating.

On 3/11/25 at 8:35 AM, Surveyor interviewed CNA M and asked when it was appropriate to complete hand hygiene. CNA M stated she performs hand hygiene when her hands are visibly soiled and when providing cares to residents. Surveyor asked CNA M if hand hygiene should be performed before eating. CNA M stated yes. Surveyor asked CNA M if she had offered the residents hand hygiene before giving them their meal trays. CNA M stated she had not.

On 3/12/25 at 8:47 AM, Surveyor interviewed DON B (Director of Nursing) and asked if she expected that staff offer hand hygiene to the residents before eating. DON B replied that yes, that was her expectation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 92 of 97 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 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41788 potential for actual harm Based on interview and record review, the facility did not ensure they followed their antibiotic stewardship Residents Affected - Few program that includes antibiotic use protocols and a system to monitor antibiotic use for 2 of 10 sampled Residents (Resident R11 and Resident R21) and 1 of 1 supplemental (Resident R73) reviewed for antibiotic stewardship.

Resident R73 was treated with an antibiotic for a urinary tract infection (UTI) and urinalysis (UA) showed Resident R73 did not have a UTI.

Resident R11 and Resident R21 were treated prophylactically with antibiotics.

Evidenced by:

The facility policy entitled, Antibiotic Stewardship Program, dated 12/23/22, states, in part: .

Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use.

Policy Explanation and Compliance: .

1a. Infection Preventionist- coordinates all antibiotic stewardship activities, maintains documentation, and serves as a resource for all clinical staff .

4. The program includes antibiotic use protocols and a system to monitor antibiotic use.

a. Antibiotic use protocols: .

ii. Laboratory testing shall be in accordance with standards of practice.

iii. The facility uses the (CDC's (Centers for Disease Control) NHSN (National Healthcare Safety Network) Surveillance Definitions, updated McGeer criteria, or other surveillance tool) to define infections .

b. Monitoring antibiotic use:

i. Monitor response to antibiotics, and laboratory results when available, to determine if the antibiotic is still indicated or adjustments should be made .

ii. Antibiotic orders obtained upon admission, whether new admission or readmission, to the facility shall be reviewed for appropriateness.

iii. Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 93 of 97 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 0881 9. Education regarding antibiotic stewardship shall be provided at least annually to facility staff, prescribing practitioners, residents, and families . Level of Harm - Minimal harm or potential for actual harm 11. Documentation related to the program is maintained by the Infection Preventionist, including, but not limited to: . Residents Affected - Few c. Antibiotic use protocols/algorithms.

d. Data collection forms for antibiotic use, process, and outcome measures .

g. Records related to education of physicians, staff, residents, and families .

McGeer revised criteria indicates the following: . Urinary tract infection (UTI) surveillance definitions .

UTI without indwelling catheter. Must fulfill both 1 AND 2.

1. At least one of the following signs or symptoms.

- Acute dysuria or pain, swelling, or tenderness of testes, epididymis, or prostate.

- Fever or leukocytosis, and greater than or equal to 1 of the following:

- Acute costovertebral angle pain or tenderness; suprapubic pain; gross hematuria; new or marked increase

in incontinence; new of marked increase in urgency; new or marked increase in frequency.

- If no fever or leukocytosis, then greater than or equal to 2 of the following:

- Suprapubic pain; gross hematuria; new or marked increase in incontinence; new of marked increase in urgency; new or marked increase in frequency.

2. At least one of the following microbiological criteria.

- Greater than 10^5 cfu/ml (colony forming unit per milliliter) of no more than 2 species of organisms in a voided urine sample.

- Greater than or equal to 10^2 cfu/ml of any organism(s) in a specimen collected by an in-and-out catheter.

UTI with indwelling catheter: Must fulfill both 1 AND 2.

1. At least one of the following signs or symptoms.

- Fever, rigors, or new-onset hypotension, with no alternate site of infection.

- Either acute change in mental status or acute functional decline, with no alternate diagnosis and leukocytosis.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 94 of 97 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 0881 - New onset suprapubic pain or costovertebral angle pain or tenderness.

Level of Harm - Minimal harm or - Purulent discharge from around the catheter or acute pain, swelling, or tenderness of the testes, epididymis potential for actual harm or prostate.

Residents Affected - Few 2. Urinary catheter specimen with greater than or equal to 10^5 cfu/ml of any organism(s).

Example 1

Resident R73 was admitted to the facility on [DATE REDACTED] and has diagnoses that include retention of urine and neuromuscular dysfunction of bladder (a condition where bladder control is lost due to damage to the nerves or brain that control bladder function).

Resident R73's UA, dated 1/24/25, does not show Resident R73 has a UTI. It shows there is bacteria present in the urine with a note next to the entry- The presence of bacteria is not necessarily indicative of urinary tract infections. WBC (white blood cells) value is 51-100, reference range is <=5/hpf (high power field), Nitrate- value- negative, reference range- negative and ph (measures the acidity or alkalinity of urine) value- 5.0 and reference range is 5.0-8.0.

On 1/25/25 at 03:45 (3:45 AM) Resident R73's progress note indicates: ED (emergency department) after visit summary given intravenous fluids symptoms improved and has UTI .ED discharge orders see at orders [sic].

The facility's resident surveillance list shows-

-Resident R73 Date of Onset- 1/25/25. Site- GU (Genitourinary) system. Signs/Symptoms/Criteria- Pain when urinating, mental changes, frequency/urgency. Diagnostics/Results- UTI. Type of Isolation- N/A (not applicable). Treatment & Intervention: Nitrofurantoin Monohyd (monohydrate) Macro Oral Capsule 100 mg (BID- Twice a day). HAI/CAI (healthcare acquired infection/community acquired infection)- HAI. Completion Well Date- 2/1/25.

On 3/10/25 at 1:30 PM, Surveyor interviewed IP D (Infection Preventionist). Surveyor asked IP D if Resident R73 should have been treated with an antibiotic for UTI. IP D indicated while looking at Resident R73's UA results absolutely not, Resident R73 did not have a UTI but family wanted her on antibiotic. Surveyor asked if IP D provided education to Resident R73's family on risk versus benefits of treating with antibiotics with Resident R73 not meeting criteria and IP D indicated he would look for documentation.

Example 2

Resident R11 was admitted to the facility on [DATE REDACTED] and has diagnoses that include chronic kidney disease stage 3 (kidneys have mild to moderate damage, meaning they're less effective at filtering waste and fluid from your blood) and type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy).

The facility's February Resident Surveillance List shows:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 95 of 97 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 0881 -Resident R11 Date of Onset- 2/15/25. Site- GU. Signs/Symptoms/Criteria-Chronic UTI Prevention. Diagnostics/Results-Prophylactic. Type of Isolation- N/A. Treatment & Intervention: Nitrofurantoin Level of Harm - Minimal harm or Macrocrystal Oral Capsule 100 mg. HAI/CAI- HAI. Completion Well Date- Consistent Usage. potential for actual harm Resident R11's February and March Medication Administration Record (MAR) shows: Residents Affected - Few -Nitrofurantoin Macrocrystal Oral Capsule. Give 100 mg by mouth one time a day for UTI prevention. Start Date- 2/15/25.

Resident R11 received Nitrofurantoin 2/15/25- 3/12/25 (current).

On 3/10/25 at 1:30 PM, Surveyor interviewed IP D (Infection Preventionist). Surveyor asked IP D if he had a conversation with PCP on Resident R11's prophylactic use on risks and benefits/antibiotic stewardship and IP D indicated nothing is documented.

Example 3

Resident R21 admitted to the facility on [DATE REDACTED] and has diagnoses that include type 2 diabetes mellitus and pressure ulcer of sacral region, unspecified stage.

The facility's January Resident Surveillance List shows:

-Resident R21- Date of Onset- 1/22/25. Site- Skin. Signs/Symptoms/Criteria-Stage 2 pressure sore with placement high in probability of infection. Diagnostics/Results-Prophylactic. Type of Isolation- N/A. Treatment & Intervention: Doxycycline Hyclate oral tablet 100 mg (BID). HAI/CAI- HAI. Completion Well Date- TBD (To be determined)- End with wound resolution.

Resident R21's January Medication Administration Record (MAR) shows:

-Doxycycline Hyclate Oral Tablet 100 mg. Give 1 tablet by mouth two times a day for antibiotic. Start Date- 12/31/24. January MAR shows Resident R21 received doxycycline 1/1/25- 1/9/25 bid and one time on 1/11/15. Then 1/22/25 Resident R21 received one time and 1/23/25-1/31/25 bid.

On 3/10/25 at 1:30 PM, Surveyor interviewed IP D (Infection Preventionist). Surveyor asked IP D if he had any documentation with PCP on Resident R21's prophylactic use and IP D indicated no. Surveyor asked why Resident R21 was

on prophylactic antibiotics and IP D indicated he would find out.

(Of note: the facility's infection preventionist did not know why Resident R21 was on a prophylactic antibiotic.)

On 3/12/25 at 2:40 PM, IP D informed Surveyor that the NP (Nurse Practitioner) will fax over communication regarding Resident R21's doxycycline. Per IP D, Resident R21 was on doxycycline by dermatology for hidradenitis suppurativa (acne inversa- a chronic skin condition featuring small painful lumps in places such as armpits or groin).

IP D did not provide any further documentation regarding Resident R21.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 96 of 97 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 0881 On 3/10/25 at 1:30 PM, Surveyor interviewed IP D (Infection Preventionist) and asked if it is appropriate to treat prophylactically with antibiotics. IP D indicated not based on nursing home recommendations but when Level of Harm - Minimal harm or primary care physician (PCP) orders prophylactic antibiotics, my hands are tied. Surveyor asked IP D if he potential for actual harm had a conversation with the PCP regarding antibiotic stewardship and prophylactic use. IP D indicated no.

Residents Affected - Few On 3/12/25 at 9:03 AM, Surveyor interviewed DON B and asked if it is appropriate to treat with prophylactic antibiotics and DON B indicated no, but the physicians do prescribe it. Surveyor asked if DON B would expect a conversation to take place with physicians on antibiotic stewardship and risks versus benefits and DON B indicated yes. Surveyor asked DON B if she would expect to see documentation on physician education and DON B indicated yes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 97 of 97 525074

F-F726.

Level of Harm - Minimal harm or Example 2: potential for actual harm

The Facility Assessment indicates the ability to care for residents receiving dialysis services. Residents Affected - Many Resident R24 receives dialysis services; however, the staff did not consistently document pre and post dialysis monitoring, nor were they able to consistently explain what they would do in case of complications or an emergency involving a dialysis patient.

On 3/10/25 at 2:46 PM, Surveyor interviewed CNA K (Certified Nursing Assistant) and asked what she would do if she walked in and saw a resident bleeding from their dialysis fistula; CNA K stated she would go get the nurse.

On 3/11/25 at 10:32 AM, Surveyor interviewed CNA T and asked what she would do if she walked in and saw a resident bleeding from their dialysis fistula; CNA T stated she would call for a nurse.

On 3/11/25 at 12:27 PM, Surveyor interviewed CNA L and asked what she would do if she walked in and saw a resident bleeding from their dialysis fistula; CNA L stated she would get the nurse right away.

It is important to note that the CNAs interviewed stated they would leave Resident R24 in her room alone while bleeding out of her dialysis site. No mention was made of applying pressure to stop the bleeding.

The facility staff failed to demonstrate the skills and competencies necessary to care for dialysis residents, putting those residents at risk.

Cross-reference

F-F880.

Level of Harm - Minimal harm or Example 5: potential for actual harm

The Facility Assessment did not address equipment such as bed rails and/or enabler bars. The facility Residents Affected - Many assessment did not indicate staff education regarding the use of bed rails and/or enabler bars, or how to assess for risk of entrapment.

11 residents were observed to have bed rails/enabler bars on their beds, including those with air mattresses.

The facility failed to ensure a system was in place to address the safe use of these assistive devices; failed to ensure alternative options were tried prior to installation; assessments were not completed; risk and benefits were not provided; and consents were not obtained prior to installing bed rails/enabler bar/assistive devices on the beds. The facility did not identify and recognize the use of siderails with an air mattress increases the risk for entrapment.

On 3/12/25 at 5:42 PM, NHA A (Nursing Home Administrator) indicated understanding regarding the need for

the facility assessment to include all staff training and competencies necessary to care for their resident population.

Cross-reference