Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 The Madison Health And Rehab during CMS and state inspections, most recent first.
A resident with a Stage IV sacral pressure injury and EBP order was observed during incontinent care and wound care with multiple infection control failures. A CNA changed gloves without hand hygiene and did not wear a gown during EBP care, and an LPN continued wound cleansing with gloves contaminated by stool without changing gloves or performing hand hygiene. The DON and IP confirmed the staff actions did not follow facility infection prevention practices.
A CNA failed to follow a resident's care plan for EBP during incontinent care by providing hands-on care without wearing a gown, despite the resident having a Stage IV sacral pressure injury and an active order for EBP. The CNA acknowledged the lapse, and the DON confirmed the resident's care plan was not followed.
A resident with a Stage IV sacral pressure injury had ordered NPWT at 125 mmHg continuous pressure, but the wound vac was observed connected and not functioning, with no illuminated screen, no sound, and no drainage moving through the tubing. The dressing later lost its seal after incontinent care, and the resident and family reported staff did not routinely monitor the device or respond promptly when the resident called for help. The wound care nurse said staff were told to notify her if the device was not working, while the DON stated routine checks of wound vac functionality were not in place.
A resident with myasthenia gravis, mobility abnormalities, and long-standing essential tremor, prescribed clonazepam 2 mg TID, had a blister pack of this controlled medication stored in a narcotics lock box discovered to be tampered with during a narcotic count by two LPNs. The foil backing for two doses was punctured and the original clonazepam tablets were missing, replaced by unidentified tablets, while records showed one of these doses documented as administered and the other as wasted. Inventory and destruction logs reflected removal and destruction of the remaining clonazepam tablets and an incorrect medication from the same blister pack. Despite interviews and drug testing of staff with access to the narcotics lock box, the facility could not determine when, how, or by whom the resident’s clonazepam was misappropriated and replaced.
The facility failed to properly label, date, and store food items in the walk-in refrigerator, as observed during a kitchen tour. The Dietary Manager confirmed that several items, including yogurt, fruit, sour cream, chicken salad, and others, were not labeled or dated correctly, leading to potential cross-contamination. Interviews with the Dietary Aide and Administrator confirmed the facility's policy requirements, highlighting a deficiency in food storage practices.
The facility failed to honor the rights of three residents to make their own health care decisions regarding their code status. Despite being cognitively intact, these residents were not consulted about their code status upon admission, and their forms were signed by family members. Interviews revealed that the residents were capable of making their own decisions, but the Social Services Director had been discussing code status with family representatives instead. The Administrator and DON confirmed that the residents should have been allowed to sign their own Advance Directives.
A facility failed to accurately code the MDS for a resident with schizophrenia, as the MDS incorrectly indicated the resident did not have a serious mental illness according to the state level II PASRR process. This error was confirmed by the MDS Nurse and the DON, who emphasized the need for accurate assessments to ensure proper care planning.
The facility failed to implement comprehensive care plans for three residents, resulting in unmet personal hygiene needs and lack of adaptive equipment during meals. A resident with dementia was found with long facial hair, another with rhabdomyolysis had excessively long fingernails, and a third resident with osteoarthritis had poor oral hygiene and was not provided with necessary adaptive meal equipment. These deficiencies were confirmed by the DON and MDS Nurse.
A resident was found to have a bottle of eye drops and a tube of pain cream in their room, which they brought from home and used without a self-administration assessment. Facility staff confirmed that medications should not be left in resident rooms without proper assessment, acknowledging the oversight and potential risk.
A resident with Dysphagia and Left Wrist Drop was not provided with necessary adaptive equipment during meals, as required by their care plan. Despite orders for a sippy cup and divided plate, the resident was served lunch on a regular plate with a goblet glass. This oversight was confirmed by the DON and dietary staff, highlighting a failure to adhere to the facility's policy on assistive feeding devices.
The facility failed to follow Enhanced Barrier Precautions (EBP) during care for two residents with indwelling medical devices. An LPN administered medication through a PEG tube without a gown, and another LPN performed catheter care without a gown, both contrary to the facility's EBP policy. The staff misunderstood the requirements, believing gowns were only necessary for open wounds or contagious conditions.
The facility failed to provide adequate ADL assistance for three residents, including nail care, oral care, and facial hair removal. A resident expressed dissatisfaction with long facial hair, while another had excessively long fingernails, both of which were acknowledged by a CNA. Additionally, a resident was observed with plaque buildup due to inadequate oral care, which the DON confirmed could lead to decay. The facility's ADL care policy was not followed, as evidenced by staff and resident interviews.
Failure to Follow Infection Control Practices During Incontinent and Wound Care
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program for Resident #2 during incontinent care and wound care. Resident #2 was admitted with diagnoses including a nondisplaced fracture of the medial condyle of the right femur, had a BIMS score of 13 indicating cognitive intactness, and had an active order for treatment of a Stage IV sacral pressure injury with NPWT and an order for Enhanced Barrier Precautions. During incontinent care, a CNA removed a brief that was visibly heavily soiled and saturated with urine, then changed gloves multiple times without performing hand hygiene between glove changes. The CNA also provided incontinent care without wearing a gown despite the resident being on EBP. During wound care, an LPN cleansed stool from the lower portion of the wound area and then, while still wearing the same gloves contaminated with fecal material, continued cleansing the wound bed and surrounding skin without changing gloves or performing hand hygiene. The LPN confirmed this practice and stated it could contaminate the wound with bacteria from stool. The DON and Infection Preventionist stated the nurse should have removed contaminated gloves and performed hand hygiene before continuing wound care, and that the CNA should have performed hand hygiene between glove changes and worn a gown as required by EBP.
Failure to Follow Enhanced Barrier Precautions During Incontinent Care
Penalty
Summary
Staff failed to follow the resident's care plan for Enhanced Barrier Precautions during incontinent care. Resident #2 was admitted with a nondisplaced fracture of the medial condyle of the right femur and had a BIMS score of 13, indicating cognitive intactness. The resident also had an active order for treatment of a Stage IV sacral pressure injury with NPWT and an order for Enhanced Barrier Precautions. The care plan identified that the resident had a pressure ulcer and directed staff to use Enhanced Barrier Precautions and follow facility protocol. During observation of incontinent care, CNA #1 provided hands-on care without wearing a gown even though the resident was identified for Enhanced Barrier Precautions. CNA #1 later confirmed she did not wear a gown and stated she should have worn one to prevent spread of infection and comply with the resident's precautions. The DON and care plan nurses stated staff were expected to follow Enhanced Barrier Precautions for residents with chronic wounds or indwelling medical devices, and the DON confirmed the resident's care plan was not followed when the CNA failed to wear a gown during care.
Nonfunctional NPWT Not Monitored for Resident With Stage IV Sacral Pressure Injury
Penalty
Summary
Physician-ordered Negative Pressure Wound Therapy (NPWT) was not monitored and maintained in working order for a resident with a Stage IV sacral pressure injury. The resident had an active order for NPWT at 125 mmHg continuous pressure with dressing changes every Monday, Wednesday, and Friday and as needed. During observation, the wound vacuum machine was connected to the resident but was not functioning, with no illuminated screen, no sounds from the unit, and no drainage moving through the tubing. On a later observation the device remained nonfunctional, and after incontinent care the dressing had lost its seal and become detached. The resident and her granddaughter stated the resident frequently remained incontinent for extended periods despite using the call light, and that urine often caused the wound vacuum dressing to lose its seal. They also stated staff did not routinely monitor the wound vacuum's function and that the resident had returned from physical therapy wet with urine and called for assistance multiple times before care was provided. The wound care nurse stated staff had been told to notify her if the wound vacuum was not working, but no one notified her when it was first observed nonfunctional. The DON stated the facility did not have routine checks of wound vacuum functionality in place, and the NP stated a wound vacuum remaining inoperable could delay wound healing and prolonged exposure to urine could contribute to breakdown of peri-wound tissue and reduce the wound's ability to heal.
Misappropriation and Tampering of a Resident’s Controlled Medication
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s property, specifically scheduled controlled medication, from misappropriation. The facility’s abuse policy defines misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings or money without consent. For one resident with a physician’s order for clonazepam 2 mg three times daily for essential tremor, a blister pack of clonazepam tablets stored in the narcotics lock box on the 100 Hall medication cart was found to have been tampered with. During a narcotics accountability count at shift change, nursing staff discovered that the foil backing for tablets numbered 16 and 17 had been punctured and that two unidentified tablets had been placed in the blister pack in place of the prescribed clonazepam. Record review showed that forty-two clonazepam 2 mg tablets had been delivered for this resident, described as white, round, scored tablets imprinted with a “2.” The controlled drug records indicated that tablet number 17 was documented as administered by an LPN and tablet number 16 was documented as wasted by the Staff Development Nurse on the same date the tampering was discovered. The controlled drug package inventory log documented that a blister pack containing thirteen remaining clonazepam tablets for this resident was removed from the narcotics lock box, and the drug wastage destruction log showed that thirteen clonazepam tablets and one incorrect medication for this resident were destroyed. The former DON placed the tampered blister pack, with the unidentified tablets taped inside, back into the narcotic lock box in the medication cart before the remaining tablets were ultimately destroyed. The resident involved had been admitted with diagnoses including myasthenia gravis, abnormalities of gait and mobility, and lack of coordination, and had an admission MDS Brief Interview for Mental Status score of 13, indicating no cognitive impairment. She reported having essential tremors for approximately thirty years and taking clonazepam for that condition, and stated that missing one dose had not affected her to her knowledge, as she experienced constant tremors with or without the medication. Despite interviews with involved staff, including the LPNs responsible for the narcotics count and the staffing coordinator who conducted drug tests on nurses with access to the narcotics lock box, the facility was unable to determine when, how, or by whom the clonazepam blister pack was tampered with and the resident’s prescribed tablets were misappropriated and replaced with unidentified tablets.
Deficiency in Food Labeling and Storage Practices
Penalty
Summary
The facility failed to adhere to its policies regarding the labeling, dating, and storage of food items in the walk-in kitchen refrigerator, as observed during a kitchen tour. The Dietary Manager (DM) confirmed that several food items, including Yoplait Vanilla Yogurt, Sysco Tropical Fruit Supreme, Wholesome Farm sour cream, chicken salad, pimento cheese, liquid eggs, chopped ham, cooked sausage and peppers, boiled eggs, chicken, and pork loin, were not properly labeled or dated. Some items were missing open dates, use-by dates, or both, and were stored in a manner that could lead to cross-contamination. The DM acknowledged that the food items should have been dated and stored correctly to prevent bacterial growth and potential illness among residents. Interviews with the Dietary Aide and the Administrator further confirmed the facility's policy requirements for labeling and dating food items upon receipt, opening, and discarding within appropriate timeframes. The Dietary Aide admitted that the items in the walk-in refrigerator were not correctly labeled, while the Administrator reiterated the importance of following the facility's policy to prevent food-borne illnesses. The observations and interviews collectively highlight a deficiency in the facility's food storage practices, which could compromise resident safety.
Failure to Honor Residents' Rights in Code Status Decisions
Penalty
Summary
The facility failed to honor the rights of three residents to make their own health care decisions regarding their code status. The facility's policy required that residents be informed of their right to choose whether to have CPR performed at the time of imminent death, with the code status form completed at admission. However, for three residents, the code status forms were signed by family members without the residents' signatures, despite the residents being cognitively intact and capable of making their own decisions. Interviews with the residents revealed that they were not consulted about their code status upon admission, and they expressed a desire to make their own decisions. Resident #10, who was admitted with chronic systolic heart failure and COPD, had a BIMS score indicating cognitive intactness, yet his code status was determined by a family member. Similarly, Resident #36, with Parkinson's disease, and Resident #48, with multiple fractures and chronic kidney disease, both had BIMS scores indicating they were cognitively intact, but their code statuses were also determined by family members. The Social Services Director admitted to discussing code status with family representatives rather than the residents themselves, and the Administrator and DON confirmed that the residents should have been allowed to sign their own Advance Directives.
Inaccurate MDS Coding for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to accurately code section A of the Minimum Data Set (MDS) for a resident with a serious mental illness. The deficiency involved a resident who had been diagnosed with schizophrenia and unspecified psychosis, as confirmed by the Preadmission Screening and Resident Review (PASRR) Summary of Findings Report. Despite this, the resident's Annual MDS inaccurately indicated that the resident was not considered to have a serious mental illness according to the state level II PASRR process. This error was confirmed during an interview with the MDS Nurse, who acknowledged the inaccuracy and the importance of accurate assessments for developing a complete plan of care. The Director of Nursing also expressed expectations for MDS assessments to accurately reflect each resident's status and plan of care.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to implement comprehensive care plans for personal hygiene and adaptive equipment for three residents. Resident #1, who has a self-care performance deficit related to dementia, was observed with long facial hair, indicating that the care plan requiring staff assistance with personal hygiene was not followed. The Director of Nursing (DON) confirmed this oversight. Resident #7, diagnosed with rhabdomyolysis, was found with excessively long fingernails, contrary to the care plan's directive to check and trim nails on bath days. This was also confirmed by the DON. Resident #2, with a self-care performance deficit due to weakness and osteoarthritis, was observed with poor oral hygiene, as evidenced by plaque buildup and food particles on her teeth. The DON confirmed that oral hygiene was not performed as per the care plan. Additionally, Resident #2 was not provided with the adaptive equipment specified in her nutritional care plan, such as a divided plate and sippy cup, during a meal observation. The DON and MDS Nurse confirmed these deficiencies, highlighting a failure to adhere to the care plan for both oral hygiene and adaptive equipment.
Improper Medication Storage in Resident's Room
Penalty
Summary
The facility failed to properly store medications, as evidenced by medications being left in a resident's room. During observations on two separate occasions, a one-ounce bottle of lubricant eye drops and a two-ounce tube of pain relief cream were found on the overbed table in the room of a resident. The resident reported that he brought these items from home and used them as needed, indicating that he self-administered these medications without an assessment for self-administration being conducted by the facility. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that medications should not be left in a resident's room without proper assessment and approval for self-administration. The LPN acknowledged the risk of other residents accessing these medications, and the Director of Nursing admitted that the situation had been overlooked. The resident involved was cognitively intact, as indicated by a BIMS score of 15, and had medical diagnoses including an unspecified injury of the left lower leg, muscle weakness, and a need for assistance with personal care.
Failure to Provide Adaptive Equipment During Meals
Penalty
Summary
The facility failed to provide a resident with the necessary adaptive equipment during meals, as observed during a dining session. Specifically, Resident #2 was served lunch on a regular plate with a goblet glass of tea and water, despite the meal ticket indicating the need for a divided plate and a sippy cup. This discrepancy was confirmed by the Director of Nursing (DON) shortly after the meal was served. The facility's policy on assistive feeding devices mandates that residents be provided with such devices to maintain or improve their ability to eat independently, and these devices should be placed on the resident's tray at the time of meal service. Resident #2 had medical diagnoses including Dysphagia and Left Wrist Drop, which necessitated the use of adaptive equipment to assist with feeding. The resident's records showed orders for a sippy cup and a divided plate with meals, dating back to November 2021. Interviews with dietary staff and the DON confirmed that the adaptive equipment should have been provided with each meal to support the resident's independence in feeding. The failure to provide the necessary equipment was a deviation from the facility's policy and the resident's care plan.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions (EBP) policy during resident care, as observed in two out of three direct care instances. Specifically, a Licensed Practical Nurse (LPN) administered medications to a resident through a Percutaneous Endoscopic Gastrostomy (PEG) tube without wearing a gown, contrary to the facility's policy that requires EBP for residents with indwelling medical devices. The LPN mistakenly believed that EBP was only necessary for residents with COVID-19 or open wounds. The resident in question had active orders for EBP related to the PEG tube and was admitted with medical diagnoses including Ventricular Fibrillation and Dysphagia. In another instance, an LPN performed catheter care and changed the drainage bag for a resident without wearing a gown, again failing to follow the EBP policy. The LPN was unaware that gowns were required for catheter care, believing they were only necessary for open wounds or contagious conditions. The resident had active orders for EBP related to a Foley catheter and was admitted with diagnoses including Malignant Neoplasm of the Prostate and Chronic Kidney Disease. The Director of Nursing confirmed that staff had been trained to use gloves and gowns for residents with indwelling medical devices, indicating a lapse in adherence to the training and policy.
Deficiency in ADL Assistance for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for three residents, specifically in the areas of nail care, oral care, and facial hair removal. Resident #1, who was cognitively intact, expressed dissatisfaction with having long facial hair, which was confirmed by a CNA who acknowledged that it should have been addressed during bath time. Resident #7, who was moderately cognitively impaired, had excessively long fingernails and expressed discomfort, stating that she had never had her nails this long before. The CNA confirmed that the nails should have been checked and clipped regularly to prevent potential harm. Resident #2 was observed with a thick white substance on her teeth and gums, indicating a lack of oral care. The CNA assigned to Resident #2 admitted that she did not brush the resident's teeth and assumed the night shift had done it. The DON confirmed the presence of plaque buildup and food particles, acknowledging that the lack of oral care could lead to decay and cavities. The facility's policy on ADL care was not adhered to, as evidenced by the observations and interviews with staff and residents.
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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 Madison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Nichols Center | 1.8 mi | ★★★★★ | 5 | 0 |
| Highland Home | 3.8 mi | ★★★★★ | 1 | 1 |
| Pine Forest Health And Rehabilitation | 8 mi | ★★★★★ | 6 | 0 |
| Manhattan Community Care Center | 8.2 mi | ★★★★★ | 7 | 1 |
| Parkway Health & Rehab Llc | 8.2 mi | ★★★★★ | 4 | 0 |
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