Madison Health And Rehabilitation Center
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
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
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.