Madison Medical Resort

Inspectors wroteBased 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. and 07/22/2026 at 1:35 a.m. 3. [...]

Inspectors wroteBased on interview and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations were thoroughly investigated for the incident and if the alleged violation was verified appropriate corrective action was taken for 2 of 3 residents (Residents #1 and #2) reviewed for abuse and neglect. 1. The facility failed to thoroughly investigate a self-reported incident with an allegation of resident abuse for Resident #1 who alleged CNA A hit his foot during incontinent care on 04/23/2026. 2. The facility failed to thoroughly investigate a self-reported incident with an allegation of resident neglect for Resident #2 who notified RN B that CNA A allegedly had left him soiled on the toilet, on 05/26/2026. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure floors were not soiled with food, grease, dust, and other dried substances. The facility failed to ensure floors in the walk-in refrigerator/freezer were not soiled with pieces of brown and clear plastic wrappers as well as dust buildup. The facility failed to ensure food items in the refrigerator were not opened to air. The facility failed to ensure food items were stored properly per the manufacturer. These failures could place residents at risk for foodborne illness and a decline in health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #55, Resident #207) of 6 residents reviewed for incontinent care and transfers in that 1. CNA D and CNA E failed to comply with enhanced barrier precaution regulations during incontinent care for Resident #55. 2. CNA B and CNA C failed to comply with enhanced barrier precaution regulations during a transfer for Resident #207. These failures could place resident's risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 3 resident (Resident #11) reviewed for privacy, in that: CNA A did not close Resident #11's window blinds while providing incontinent care for the resident. This deficient practice could place residents who received perineal care at risk of loss of dignity due to lack of privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 2 (Residents #61 and #253) of 4 residents observed for oxygen management. The facility failed to ensure Oxygen (O2) in use signage was on the doorways of Resident #61 and Resident #253. This failure could place residents at risk of not receiving appropriate respiratory care .

Inspectors wroteBased 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. The IJ was removed on 02/01/24, but the facility remained out of compliance. [...]

Inspectors wroteBased 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. The IJ was removed on 02/01/24, but the facility remained out of compliance. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident environment remains as free of accident hazards as is possible for 2 of 5 residents (Residents #2, and #68 ) reviewed for accidents and hazards in that: CNA B, CNA C, and CNA D failed to lock Resident #2 and Resident #68's wheelchair during transfers. This deficient practice could place residents at risk for avoidable injuries during transfers.

Inspectors wroteBased on observation, interview and record review the facility failed to store all drugs and biologicals in locked compartments for 1 of 1 treatment cart reviewed for medication storage and security. The facility staff failed to ensure the treatment cart was secured when it was left unattended and unsupervised. These failures could place clients at risk for drug diversion or accidental ingestion.