Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Madison Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities had lower dentures reported missing, and staff documented notification of social services and a Speech therapy request but did not document a timely dental referral or offer of denture replacement in line with facility policy. Social services informed the resident’s representative of a $1200 replacement cost and agreed to wait for Medicaid approval, without documenting that the facility might assume financial responsibility as required by policy. The representative later reported not being told the facility could cover costs and stated the resident had difficulty eating and required soft foods after the dentures were lost, while facility leadership acknowledged the facility probably should have offered to pay and could not locate the resident’s admission inventory sheet.
Failure to Follow Infection Control and Enhanced Barrier Precautions: Staff did not consistently follow infection control practices, including hand hygiene, PPE use, and aseptic technique. An LPN touched medications with bare hands, staff entered a resident’s room on contact precautions and provided care with gloves only, and a disconnected foley catheter was reconnected without cleaning the ends. An RT changed oxygen tubing without hand hygiene, and a CNA exited a room while still wearing an isolation gown. Facility leaders stated they expected staff to follow infection control policies, and the Regional Quality Nurse stated she had not performed staff training at the facility.
Unsafe and Unclean Resident Room Conditions: Multiple resident rooms and an oxygen storage entrance had black substances on baseboards and floors, cracked or missing tiles, missing baseboards, wall damage, and a hole near a tub faucet. The DON said she was unaware of the issues, the Maintenance Director said he had not received work orders for some of the damage, and the Administrator stated staff were expected to report building problems and residents should have a clean and safe environment.
The facility failed to update and revise care plans for four residents, leading to unmet bathing preferences and hygiene issues. One resident, with cerebral infarction and mood disorder, was not provided showers at preferred times or with preferred staff, resulting in body odor and distress. Another resident with multiple sclerosis and quadriplegia was dissatisfied with bed baths due to staffing issues. A third resident went weeks without showers due to late-night scheduling, and a fourth resident's care plan lacked documentation of transfer assistance and shower preferences.
The facility failed to maintain personal hygiene for several residents, with issues stemming from inadequate scheduling and staffing. Residents were not receiving showers as scheduled, often being woken up at night, leading to refusals without rescheduling. Observations noted residents with noticeable body odor and feelings of embarrassment. Interviews revealed that the facility was aware of the issues and was adjusting the shower schedule, but documentation and follow-up on refusals were lacking.
A facility failed to accurately assess a resident's nutritional intake through parenteral or tube feeding, as indicated in the MDS. The resident was observed with tube feeding disconnected, and staff interviews revealed confusion about feeding orders and responsibilities for calorie counts. The dietician, new to the facility, was unaware of any calorie counts being completed, and the facility relied on resident weights instead of calorie counts to assess nutritional status.
A resident with a gastrostomy tube did not receive continuous tube feeding as ordered, with staff frequently disconnecting the feeding during the day. The LPN was unaware of the continuous feeding order, and the dietician did not track the resident's calorie intake, relying instead on weight monitoring. The facility failed to ensure adherence to physician orders, resulting in unmet nutritional needs.
The facility was found deficient in its infection prevention and control program. An LPN failed to perform hand hygiene before glove use, risking germ spread. Additionally, unopened briefs were improperly stored on the floor, posing a contamination risk. Staff interviews confirmed these actions violated facility policies, which were recently reviewed.
Failure to Provide Timely Dental Referral and Replacement for Missing Dentures
Penalty
Summary
The facility failed to ensure timely dental referral and appropriate follow-up for a resident whose lower dentures were reported missing, resulting in a deficiency related to provision of routine and 24-hour emergency dental care. The resident had diagnoses including Alzheimer's disease, cerebral infarction, hemiplegia, and hypertension, and a BIMS score indicating severe cognitive impairment. A nurse documented that the resident’s responsible party reported the lower dentures missing, the Social Services Director (SSD) was notified, and a Speech therapy evaluation was requested, with documentation that the resident voiced no chewing or swallowing difficulties at that time. An IDT note reiterated the missing dentures and the Speech therapy request. The facility’s dental services policy required prompt dental referrals and stated that if the facility was responsible for lost dentures, it would incur replacement costs. Subsequent documentation by the SSD showed that the resident was pending Medicaid and that the contracted dental provider required full payment before denture replacement, and the SSD discussed Medicaid status and cost estimates with Administration. The SSD completed a missing item form and documented a grievance/concern form noting that the responsible party was informed the replacement cost would be $1200 and agreed to wait for Medicaid approval, but there was no documentation of a dental referral or that the facility offered to assume financial responsibility as outlined in policy. The responsible party later stated she was never informed the facility would cover any cost, reported that the resident had difficulty eating and required small bites and soft foods after losing the dentures, and indicated the resident would likely need a full set of dentures due to the delay. The SSD acknowledged she did not inform the responsible party that the facility could be responsible for the cost, and both the Administrator and Senior Administrator stated the facility probably should have offered to cover the cost, with the Senior Administrator also noting that the resident’s admission inventory sheet could not be located.
Failure to Follow Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for five of 28 residents on three of three hallways. Review of facility policies showed expectations for resident dignity, infection control, hand hygiene, cleaning and disinfection of resident care items and equipment, and use of transmission-based precautions, including posting appropriate signage and following PPE instructions. Enhanced Barrier Precautions signage posted outside resident rooms stated that everyone must clean their hands before entering and when leaving the room. During observation, oxygen tubing was found unbagged and on the floor in one resident room, and a second oxygen tubing was unbagged on a sink in another resident room. An LPN removed medications from a packet and placed them into ungloved hands before putting them into a container for administration. The LPN later stated this was an accident and acknowledged that improper infection control could spread infections that could make residents sick, cause hospitalization, or death. For a resident admitted with corticobasal deterioration, dementia, and UTI, with a BIMS score of 3 of 15 and a physician order for contact precautions due to UTI, staff entered the room while the resident was partially sliding out of bed and had a bowel movement and a partially removed brief. Two staff members provided care with gloves only despite Enhanced Barrier Precautions signage. The resident’s foley catheter had become disconnected from the drainage tubing, and the LPN reconnected the tubing without cleaning the ends. The LPN stated she should have followed Enhanced Barrier Precautions, including handwashing and gown use, and should have cleaned the catheter ends before reconnecting them. The SRNA stated she knew PPE should have been used but prioritized the resident’s immediate safety. Additional observations showed an RT entered rooms with Enhanced Barrier Precautions signage and changed residents’ oxygen tubing without washing hands before entering or after exiting the room. A CNA exited a room with Enhanced Barrier Precautions signage while still wearing an isolation gown and stated the gown should have been removed before leaving the room. The DON stated staff were not always compliant with proper hand hygiene during walkthroughs, the Regional Quality Nurse stated she had not performed staff training at the facility, and the Infection Preventionist and Administrator both stated they expected staff to follow infection control protocols.
Unsafe and Unclean Resident Room Conditions
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for five of 28 sampled residents on one hallway. During observations, Resident 6’s room had a black substance on the floor around the baseboard, and three tiles in the bathroom floor were cracked. Resident 7’s room had a black substance on the bathroom baseboard, and parts of the baseboard were missing around the air condition unit. Resident 64’s room had a black substance on the baseboards, missing baseboards underneath the air condition unit, and a hole in the wall under the bottom of the unit. Resident 37’s room had a crack in the wall behind the bed, no baseboard behind the bed, and a hole in the top of the tub near the faucet. The oxygen storage entrance also had a black substance around the bottom of the door. The Maintenance Director stated work orders were prioritized and generally completed within 24 hours, but he had not received any new work orders and was not aware of the broken or missing tiles. The DON stated she was unaware of the black substance on the walls or baseboards and said housekeeping should notify her if something like that was found. The Administrator stated it was his expectation that staff complete work orders whenever something was wrong with the building and that residents should always have a clean and safe environment.
Deficiencies in Resident Care Plans and Bathing Preferences
Penalty
Summary
The facility failed to maintain an effective system for updating and revising resident care plans to include individualized interventions, affecting four residents. Resident 79, admitted with multiple diagnoses including cerebral infarction and mood disorder, was cognitively intact and expressed a preference for shower times and assistance from female staff. However, the care plan did not reflect these preferences, leading to the resident experiencing body odor and distress due to being woken up after midnight for showers, which he refused. Resident 36, diagnosed with multiple sclerosis and quadriplegia, was also cognitively intact and dependent on staff for bathing. The care plan indicated the use of a shower bed, but did not address the resident's preference for shower times or the assistance required for transferring. The resident expressed dissatisfaction with receiving bed baths instead of showers, citing staffing issues as the reason for the lack of showers. Resident 64, with a history of listerial sepsis and other conditions, was supposed to receive showers twice a week but reported going four weeks without one due to being woken up late at night. Similarly, Resident 84, with hemiplegia and other diagnoses, was dependent on staff for bathing and preferred no male caregivers. The care plan lacked documentation of the resident's need for assistance with transfers and did not reflect shower preferences. The facility's interim administrator acknowledged that care plans should be person-centered, but the facility had not yet addressed specific shower preferences in care plans.
Deficiency in Resident Hygiene Maintenance
Penalty
Summary
The facility failed to ensure that residents received appropriate treatment and services to maintain personal hygiene, specifically bathing, for five residents. The facility's policy on Activities of Daily Living (ADLs) lacked specifics on the provision of these services, and the shower schedule was based on room numbers rather than individual needs or preferences. Observations and interviews revealed that residents were not receiving showers as scheduled, and refusals were often marked without offering rescheduling or alternative solutions. One resident, admitted with multiple diagnoses including cerebral infarction and mood disorder, was cognitively intact and expressed a preference for showers. However, the resident was not offered showers twice a week as scheduled and was often woken up at midnight for showers, leading to refusals. The resident reported feeling embarrassed by body odor and missed activities due to feeling unclean. Another resident, dependent on staff for bathing due to multiple sclerosis and quadriplegia, was not provided showers due to staff shortages and isolation protocols, leading to feelings of being dirty and unclean. Additional residents also experienced similar issues, with one resident going weeks without a shower due to late-night scheduling and another resident not receiving showers due to staff shortages. Interviews with staff and administrators revealed that the facility was aware of the scheduling issues and was in the process of adjusting the shower schedule. However, the lack of documentation and follow-up on refusals, as well as the inadequate staffing levels, contributed to the deficiency in maintaining residents' personal hygiene.
Inaccurate Nutritional Assessment for Resident
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident, identified as R74, regarding the proportion of total calories received through parenteral or tube feeding. The Quarterly Minimum Data Set (MDS) for R74, with an assessment reference date of 07/17/2024, indicated that the resident received 51% or more of their total calories through these methods. However, there was no evidence that a calorie count was completed to determine the actual nutritional intake from tube feeding or oral intake. Observations over several days showed R74 with the tube feeding disconnected, and interviews revealed a lack of awareness and misunderstanding among staff regarding the resident's feeding orders. The facility's dietician, who started in August 2024, was unaware of any calorie counts being completed and relied on nursing services for such reports. The Director of Nursing confirmed that the facility did not perform calorie counts and instead used resident weights to assess nutritional status. Interviews with various staff members, including the LPN MDS Nurse and the Account Manager of Healthcare Services Group, indicated that the responsibility for completing the Swallowing/Nutritional Status section of the MDS and obtaining calorie counts was unclear, with the dietician being identified as responsible for these tasks.
Failure to Follow Enteral Nutrition Orders
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube had their nutritional needs met and that the administration of enteral nutrition was consistent with the practitioner's orders. The resident, who was admitted with diagnoses including esophageal obstruction and acute kidney failure, had physician's orders for continuous tube feeding at 75 ml/hour for 22 hours a day. However, observations revealed that the resident's tube feeding was frequently disconnected during the day, with significant amounts of formula remaining unused. Interviews with the resident and staff indicated that the tube feeding was often disconnected from morning until bedtime, contrary to the continuous feeding order. Staff interviews revealed a lack of awareness and adherence to the physician's orders. An LPN, unfamiliar with the resident's care plan, mistakenly believed the feeding was bolus rather than continuous. The dietician, who had not completed calorie counts for the resident, was unsure of the actual nutritional intake and relied on weight monitoring to assess nutritional status. The Director of Nursing and the Administrator both acknowledged the expectation for staff to follow physician orders and report any issues, but this was not effectively implemented, leading to the deficiency in care.
Infection Control Deficiencies Observed in Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observations and interviews. On one occasion, an LPN was observed not performing hand hygiene before putting on gloves after touching a doorknob, despite being aware of the requirement to do so. This lapse in protocol was acknowledged by the LPN, who admitted to forgetting due to nervousness and recognized the risk of spreading germs to residents and potentially contracting an infection herself. Additionally, during a facility tour, a pack of unopened briefs was found lying on the floor in a resident's room, which was identified as an infection control issue by a CNA and a KMA. Both staff members acknowledged that the briefs should have been stored properly in the resident's closet to prevent contamination. The Infection Preventionist and the Director of Nursing confirmed that these actions were against the facility's infection control policies, which were recently reviewed with staff. The Administrator also emphasized the importance of following these policies to prevent the spread of infection.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Richmond
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kenwood Health And Rehabilitation Center | 0 mi | ★★★★★ | 0 | 0 |
| Telford Terrace | 1.8 mi | ★★★★★ | 3 | 0 |
| Berea Health And Rehabilitation | 9.9 mi | ★★★★★ | 0 | 0 |
| The Terrace Nursing And Rehabilitation Center | 10.2 mi | ★★★★★ | 0 | 0 |
| Landmark Of Lancaster Rehabilitation And Nursing C | 17.1 mi | ★★★★★ | 4 | 0 |
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