Madison Medical Resort

In the surveyor’s words

From the most serious findings on record at Madison Medical Resort, in the surveyor’s own words.

• Immediate jeopardy, patternF656Feb 1, 2024

  Based on observation, interview and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 6 (Residents #1, 11, 6, 8, 10, and 7) of 6 residents reviewed for care plans. The facility failed to develop and implement a comprehensive person-centered care plan that included transfer goals and interventions for Residents #1, 11, 6, 8, 10, and 7. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/31/24. The IJ template was provided to the Administrator. […]

• Immediate jeopardy, patternF689Feb 1, 2024

  Based on observation, record review, and interview the facility failed to ensure residents were provided supervision and assistive devices to prevent accidents for 6 of 6 (Residents #1, 11, 6, 8, 10, and 7) residents reviewed for accidents. The facility allowed CNAs to determine the amount of assistance to provide to each resident and determine if they could transfer residents alone or ask for assistance. Resident #1 had a fall on 12/7/23 during transfer and was injured with acute fracture of the surgical neck of the left humerus. Resident #11 had slipped and landed on floor on 12/12/23 during a transfer with no injuries. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/31/24. The IJ template was provided to the Administrator. […]

• Actual harm, isolatedF689Aug 27, 2021

  Based on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for was provided 1 of 4 residents (Resident #177) reviewed for transfers. The facility failed to ensure CNA A and CNA B transferred Resident #177 in a manner to prevent injuries on 8/18/21. As a result, Resident #177 sustained a spiral fracture to her right arm. This failure could place residents who required assistance during transfers at risk for pain and significant injury. […]

• No harm, potential for more than minimal, patternF693Jul 23, 2026

  Based on observation, interview and record review the facility failed to ensure a resident who was fed by eternal means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of eternal feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers for 3 of 5 residents (Residents #3, #9 and #10) reviewed for PEG tube feeding. 1. The facility failed to ensure Resident #3's enteral feedings bag was correctly dated when it was changed on 07/21/2026 at 9:07 a.m. 2. The facility failed to ensure Resident #3 was in a proper position while on continuous enteral formula to mitigate the potential for aspiration on 07/21/2026 at 9:21 a.m. […]

• No harm, potential for more than minimal, patternF656Apr 2, 2026

  Based on interview and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 10 of 10 (Resident #5, Resident #6, Resident #12, Resident #44, and Resident #58, Resident #61, Resident #65, Resident #100, Resident #113, Resident #133) residents reviewed for comprehensive person-centered care plans. 1. […]