Madison Health And Rehabilitation Center
MADISON HEALTH AND REHABILITATION CENTER in MADISON, WI — inspection on March 25, 2025.
Found 5 citations. 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
The facility failed to ensure R223 was placed in proper transmission-based precautions. R32, R44, and R47 also tested positive after R223 was diagnosed with ESBL.
Three of the residents resided on the same hall.
Facility had no evidence precautions were put into place for R223, R32, R44, and R47 with confirmed ESBL.
Staff did not complete hand hygiene according to Standards of Practice during cares for R25 and R74.
Staff did not handle soiled linens appropriately.
During 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.
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
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.
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 R25 refusing repositioning. 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). 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 R25's sacrum wound was assessed as a stage IV and found to be infected.
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
The facility failed to ensure R223 was placed in proper transmission-based precautions. R32, R44, & R47 also tested positive after R223 was diagnosed with ESBL.
Three of the residents resided on the same hall.
Facility had no evidence precautions were put into place for R223, R32, R44, & R47 with confirmed ESBL.
Staff did not complete hand hygiene according to Standards of Practice during cares for R25 & R74.
Staff did not handle soiled linens appropriately.
During 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:
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
F-F726.
potential for actual harm The Facility Assessment indicates the ability to care for residents receiving dialysis services.
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 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
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