Madonna Manor Nursing Home

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were accurately labeled and stored in accordance with acceptable professional standards. Specifically, in one of three medication carts reviewed the facility failed to ensure medications were stored in their original packaging.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents received food prepared by methods that conserve nutritive value, flavor and appearance and was palatable, attractive and at a safe and appetizing temperature for one of two test trays.

Inspectors wroteBased on observation and interview, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to:1. Ensure the main kitchen grout and coving was maintained in a sanitary and safe condition; and2. Ensure ready to eat foods (food which does not require cooking or further preparation prior to consumption) were handled utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another) during tray line service.

Inspectors wroteBased on interview and record review, the facility failed to ensure one Resident (#9), out of a total sample of 18 residents, was referred to see a Neurologist as recommended by the Psychiatrist and the Primary Physician.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure infection prevention and control measures were implemented to prevent the potential transmission of infections for one Resident (#33), out of a total sample of three residents observed for medication administration. Specifically, the facility failed to ensure staff followed safe injection standard practices, by recapping used needles after the administration of insulin.

Inspectors wroteBased on employee record review and interview, the facility failed to ensure the new hire employee records contained evidence of the 2024-2025 COVID-19 vaccination for two of five newly hired employees. Specifically, the facility failed to ensure the employee record contained evidence of the COVID-19 vaccination or proof the newly hired employees were offered an updated COVID-19 vaccine when he/she was eligible.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who required physical assistance from staff for positioning, the Facility failed to ensure they maintained a complete and accurate medical record, related to Certified Nurse Aide (CNA) Positioning Sheets, when daily documentation by CNA's (for all three shifts) was not consistently completed and positioning sheets were often left completely blank. Findings Include: Review of the Facility's Policy tilted CNA Documentation, dated as revised 10/05/2021, indicated the Certified Nurses' Aides will provide accurate documentation daily on each shift using the Electronic Medical Record (EMR). [...]

Inspectors wroteBased on interview and document review, the facility failed to notify the physician of an ongoing and significant weight loss for one Resident (#26), out of a total sample of 18 residents.

Inspectors wroteBased on record review, interviews, and documentation review, the facility failed to ensure acceptable parameters of nutritional status were maintained for one Resident (#26), out of 18 sampled residents. Specifically, the facility failed to ensure ideal or usual body weight was maintained and interventions implemented and re-evaluated to prevent significant and ongoing weight loss for the Resident which was unplanned and undesired.

Inspectors wroteBased on a resident group meeting, staff interviews, and document review, the facility failed to ensure concerns from the Resident Council were documented to ensure they were acted upon timely and included the facility response.

Inspectors wroteBased on interviews, document review, and observations, the facility failed to have information on how to file a grievance in resident care and public areas and have forms accessible, so residents and/or visitors were able to anonymously notify the facility of their concerns.

Inspectors wroteBased on record review, interview, and document review, the facility failed to evaluate the use of a one-piece jumpsuit as a restraint for one Resident (#67), to ensure it was the least restricted device and necessary, out of a total sample of 18 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure one Resident (#13), out of a total sample of 18 residents, was treated with respect and dignity. Specifically, the facility failed to ensure staff provided a privacy cover for Resident #13's Foley catheter (tube inserted into the bladder to drain urine) drainage bag when the bag was exposed, containing urine, and visible for others to see.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatment and services for the care of an indwelling catheter (tube inserted into the bladder to drain urine into a collection bag outside the body) for one Resident (#13), out of total sample of 18 residents. Specifically, the facility failed to ensure the Resident's indwelling Foley catheter device was maintained in a sanitary manner.

Inspectors wroteBased on observation and interview, the facility failed to maintain sanitary conditions of continuous positive airway pressure (CPAP- respiratory machine used to assist in keeping airways open to ease breathing while sleeping) respiratory tubing and equipment for one Resident (#3), out of a total sample of 18 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and potential transmission of communicable diseases. Specifically, the facility failed: 1. For Resident #51, to ensure staff wore PPE as required for Isolation/Droplet Precautions (infection control precautions used for residents who are infected with certain infectious agents including COVID-19 for which additional precautions are needed to prevent infection transmission) while entering the room to provide care; and 2. [...]

Inspectors wroteBased on records reviewed and interviews for three of three residents (Resident #1, Resident #2, and Resident #3), who developed rashes and/or had changes in their skin conditions, the Facility failed to ensure they maintained complete and accurate medical/clinical records including but not limited to documentation related to weekly skin assessments which included completion of a wound management assessment as needed, and the monitoring of treatments and progress towards healing. Finding Include: Review of the Facility Policy titled Wound (any type of damage or breakage on the surface of the skin) and Skin Care Protocol, dated as last revised 1/2009, indicated that the purpose is to identify outcomes-based approaches for the care of residents identified at risk and those with existing wounds. [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #2), whose Plan of Care indicated he/she required physical assistance of one staff member with toileting which included assistance with hygiene care needs, utilized bed/chair alarms for safety and was assessed by nursing at high risk for falls, the Facility failed to ensure nursing staff consistently implemented and followed interventions from his/her Plan of Care while meeting his/her care needs. On 08/30/23, Certified Nurse Aide (CNA) #1 brought Resident #2 into the bathroom, transferred and positioned him/her onto the toilet (which was not alarmed), CNA #1 then exited the bathroom and Resident #2's room, leaving him/her unattended and unassisted by a staff member. [...]

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #2), who was assessed by nursing at high risk for falls, whose Plan of Care indicated that he/she required physical assistance with toileting care needs, including transfers on and off the toilet, the Facility failed to ensure he/she was provided with the required level of staff assistance to maintain his/her safety, in an effort to prevent incidents/accidents resulting in an injury. On 08/30/23, Certified Nurse Aide (CNA) #1 brought Resident #2 into the bathroom, assisted with transferring and positioning him/her on the toilet (which was not equipped with an alarm) and then left the bathroom and Resident #2's room leaving him/her unattended by a staff member. [...]

Inspectors wroteBased on observation, record review, policy review, and interviews, the facility failed to ensure its staff provided each resident an environment free of accident hazards and adequate supervision and assistance devices to prevent potential accidents or injuries. Specifically, the facility failed: 1. For one Resident (#48), out of a total sample of 19 residents, to ensure effective interventions were implemented to prevent three falls, including one with injury, requiring transfer to an acute care hospital; and 2. To ensure the Treatment Room door was closed and locked, exposing wandering residents to an environment with medication and medical supply hazards, on one of three units.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents in three of four dining rooms had a comfortable and homelike dining experience.

Inspectors wroteBased on observations, policy review, and interviews, the facility failed to ensure staff implemented infection prevention and control practices and policies. Specifically, the facility failed to ensure Nurse #1 performed hand hygiene between three residents during medication administration.

Inspectors wroteBased on observation, policy review, and interview, the facility failed to ensure staff provided privacy during a medical treatment for one sampled Resident (#63), out of 19 sampled residents.

Inspectors wroteBased on record review, policy review, and interviews, the facility failed to update and revise the activity of daily living functional status/rehabilitation potential care plan for one Resident (#16), out of a sample of 19 residents. Specifically, the facility failed to revise the care plan after the discontinuation of bilateral hand splints used for the management of contractures.

Inspectors wroteBased on interview and record review, the facility failed to ensure assistive devices to maintain hearing and enhanced communication were utilized for one Resident (#66), out of a total sample of 19 residents. Specifically, the facility failed to assess for the presence of hearing aids on admission.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure interventions were implemented for the treatment of bilateral hand contractures for one Resident (#16), out of a sample of 19 residents. Specifically, the facility failed to ensure a right-hand carrot (orthotic positioning device) and left hand roll (orthotic device to prevent skin breakdown) was in place, as ordered by the Physician.

Inspectors wroteBased on record review, policy review, and interviews, the facility failed to ensure that pharmacy recommendations were reviewed and addressed for one Resident (#30), out of a total sample of 19 residents.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure the advanced directives code status was accurately reflected in the medical record for one Resident (#9), out of a total sample of 19 residents.

Inspectors wroteBased on record review, document review, policy review, and interview, the facility failed to ensure Hospice provided information and documentation regarding care and services as required in the provider contract agreement, including a designated facility coordinator for two Residents (#24 and #71), out of total sample of 19 residents. Specifically, the facility failed: 1. For Resident #24, to ensure the hospice service provider completed hospice information in the Resident's record, which included the most current Hospice Plan of Care, Physician Recertification of Terminal Illness, and a schedule of hospice services to be provided in order to assure coordination and collaboration of care; and 2. [...]