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Complaint Investigation

Madison Health And Rehabilitation Center

March 25, 2025 · Madison, WI · 110 Belmont Rd.
Citations 1
CMS Rating 1/5
Beds 83
Provider ID 525074
Healthcare Facility
Madison Health And Rehabilitation Center
Madison, WI  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)  ·  40 pages
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Madison Health and Rehabilitation Center in Madison, WI — inspection on March 25, 2025.

Found 1 citation. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF700
Immediate (ARD) of 3/5/25, indicates R61 has a Brief Interview for Mental Status (BIMS) score of 04 indicating R61 is Some for repositioning and turning in bed .Transferring .The resident is totally dependent on 2 staff for transferring affected

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

525074

Form Approved OMB

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

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Madison, WI, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Madison Health and Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.