Madison Health and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Madison Health and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF600Aug 27, 2025

  Based on observations, record review and resident, staff and Medical Doctor interviews, the facility failed to protect a resident's (Resident #2) right to be free from physical abuse when a resident (Resident #1) with moderate cognitive impairment and no previous history of behaviors or aggression, hit Resident #2 in the face, head and neck causing injuries. Resident #1 continued to show aggression toward staff members until Nurse Aide (NA) #1 was able to get him redirected back to his bed at which point Resident #1 stated he had injured Resident #2. Resident #2 was immediately removed from the room and sent to the hospital for further evaluation. […]

• Actual harm, isolatedF580Feb 18, 2022

  Based on record review and staff, Nurse Practitioner (NP), and Physician interviews the facility failed to notify the Physician of a new pressure injury for 1 of 3 residents (Resident #130) reviewed for pressure ulcers. Findings included: Resident #130 was admitted to the facility 07/16/21 with one unstageable pressure ulcer covered with slough/eschar (dead tissue) and was readmitted to the facility 11/01/21. A Wound Management Detail report dated 11/02/21 revealed Resident #130 was readmitted to the facility 11/01/21 with a new deep tissue injury (DTI) to the lateral (side) aspect of his left heel which was 100% covered with thick, dry, necrotic (dead) tissue. The report also stated Resident #130's existing left heel ulcer was larger in size and had purulent (pus) drainage. […]

• Actual harm, isolatedF686Feb 18, 2022

  Based on record review and staff and Nurse Practitioner (NP) and Physician interviews the facility failed to assess for the development of a pressure ulcer and failed to obtain pressure ulcer treatment orders from a Physician for 1 of 3 residents (Resident #130) reviewed for pressure ulcers. Findings included: Resident #130 was admitted to the facility 07/16/21 with one unstageable pressure ulcer covered with slough/eschar (dead tissue) and was readmitted to the facility 11/01/21. A Wound Management Detail report dated 11/02/21 revealed Resident #130 was readmitted to the facility 11/01/21 with a new deep tissue injury (DTI) to the lateral (side) aspect of his left heel which was 100% covered with thick, dry, necrotic (dead) tissue. […]

• No harm, potential for more than minimal, patternF812Feb 11, 2026

  Based on observations and staff interviews, the facility failed to discard food with signs of spoilage and remove expired food items in 1 of 1 walk-in cooler; maintain a clean and sanitary ice machine for 1 of 1 ice machine; date an opened food item in 1 of 1 dry storage room; and label and date opened food items for 1 of 1 kitchen. These practices had the potential to affect food served to residents. Findings included:a. An initial observation of the kitchen on 02/08/26 (Sunday) at 9:27 AM made without staff present revealed the following: - an undated bin of sugar- an undated bin of flour- an undated bin of cornmealb. […]

• No harm, potential for more than minimal, patternF812Nov 15, 2024

  Based on observations and staff interviews the facility failed to remove expired food from 1 of 3 kitchen refrigerators (walk-in refrigerator). This practice had the potential to affect food served to residents. Findings Included An observation of the walk-in refrigerator in the kitchen on [DATE] at 9:40 AM with the Dietary Manager (DM) found one resealable plastic bag dated ,d+[DATE] that contained deli meat. The DM stated during the observation that opened and stored food should be kept for 7 days and then thrown out; she immediately removed the food. The DM stated the morning cook checks the walk-in refrigerator each morning for food out of date and discarded them. […]