Deficiency Records for Madison Health and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Madison Health and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-11-17 | 2023-12-23 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-11-17 | 2023-12-23 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2023-11-17 | 2023-12-23 | N |
| Provide activities to meet all resident's needs. | Health | 2023-11-17 | 2023-12-23 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-11-17 | 2023-12-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-17 | 2023-12-23 | N |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2023-11-17 | 2023-12-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-01 | 2023-07-29 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-07-01 | 2023-07-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-01 | 2023-07-29 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-07-01 | 2023-07-29 | Y |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-07-01 | 2023-07-29 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-07-01 | 2023-07-29 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-06-28 | 2023-07-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-28 | 2023-07-29 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-28 | 2023-07-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-06-28 | 2023-07-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-28 | 2023-07-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-06-28 | 2023-07-29 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-03-04 | 2022-07-05 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-03-04 | 2022-07-05 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-04 | 2022-03-31 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-04 | 2022-03-31 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-03-04 | 2022-03-31 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-03-04 | 2022-03-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-04 | 2022-03-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-04 | 2022-03-31 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-03-04 | 2022-03-31 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-03-04 | 2022-03-31 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-03-04 | 2022-03-31 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-04 | 2022-03-31 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-04 | 2022-03-31 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-03-04 | 2022-03-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-04 | 2022-03-31 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-04 | 2022-03-31 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-03-04 | 2022-03-31 | Y |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2022-03-04 | 2022-03-31 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-04 | 2022-03-31 | Y |
