The Madison Health and Rehab

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Jan 16, 2025

  Based on observations, staff interviews, and facility policy review the facility failed to ensure items in the walk-in kitchen refrigerator were labeled and dated, discarded by the expiration date, and arranged in a manner to prevent possible cross-contamination for one (1) of three (3) kitchen tours Findings include: Review of the facility policy titled, Labeling and Dating Inservice revised 2/2023, revealed All foods should be dated upon receipt before being stored. Food labels must include: The food item name, the date of preparation/receipt/removal from freezer, and the use by date.Leftovers must be labeled and dated with the date they are prepared and the use by date. […]

• No harm, potential for more than minimal, widespreadF812Apr 7, 2022

  Based on observation, facility policy review, and staff interviews, the facility failed to prevent possible food contamination as evidenced by observations during the initial kitchen tour of improper thawing of raw chicken and three (3) and one-half (,d+[DATE]) loaves of expired sliced sandwich bread, for 51 of 53 residents receiving dietary trays. Findings include: Record review of facility policy titled, Thawing Food revised ,d+[DATE] revealed, Policy: The facility shall ensure that foods served to residents are thawed in a manner to prevent contamination. PROCEDURE: Frozen food is thawed in one of these ways: 2. Running water .b. Completely submerge food under running potable (drinking) water at 70 degrees or below. Review of facility policy titled, FOOD STORAGE LABELING . […]

• No harm, potential for more than minimal, widespreadF888Apr 7, 2022

  Based on observation, staff interview, record review, and facility policy review the facility failed to prevent the possible spread of COVID-19 as evidenced by failure to fully implement their policy to ensure that all staff are fully vaccinated or received an exemption for two (2) of 97 employee records reviewed. Findings Include: Record review of the facility policy titled, Employee COVID-19 Vaccinations undated, revealed It is the policy of this facility to ensure that all eligible employees are vaccinated against COVID-19 as per applicable Federal, State and local guidelines . Compliance Guidelines: 1. The facility will ensure that all eligible employees are fully vaccinated against COVID-19, unless religious or medical exemptions are granted. 2. […]

• No harm, potential for more than minimal, widespreadF919Apr 7, 2022

  Based on observations, staff interviews, record reviews, and facility policy review the facility failed to provide a sufficient volume level on the resident call light system as evidenced by the inability to hear the call light system alarm on the nursing unit halls for four (4) of 4 days of survey. Findings include: Review of the facility policy titled, Call Light, Answering, undated, revealed, Purpose - The purpose of this procedure is to respond to the resident's requests and needs . An observation on 4/4/22 at 10:30 AM, revealed the call light globes, located above the resident room doors would light up when the call light system was activated, but no call light system alarm was heard on the nursing unit halls to alert the staff that the call light was activated. […]

• No harm, potential for more than minimal, patternF880May 27, 2026

  Based on observation, record review, staff interviews, and facility policy review, the facility failed to implement and maintain an effective infection prevention and control program for one (1) of three (3) residents reviewed for infection control practices. (Resident #2)Findings Include: Record review of the facility policy Enhanced Barrier Precautions dated 10-23 revealed, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms . Record review of the facility policy Hand Hygiene Policy dated 5-25 revealed, .6. a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. […]