Madonna Manor

Inspectors wroteBased on observation, interview, and review of the facility's policies, the facility failed to store and prepare foods under sanitary conditions. Observations on 09/30/2025, 10/01/2025, and 12/03/2025 included cleaning cloths lying on the counter and not in the sanitizer bucket, trash cans without lids in the food production area, and foods in the dry storage area not labeled, dated, and expired. This deficient practice had the potential to affect all 53 current residents.

Inspectors wroteBased on observation, interview, record review, review of a disinfectant label, and review of the facility's policies, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases by ensuring staff involved in direct resident contact followed hand hygiene procedures and wore required personal protective equipment (PPE) for 1 of 16 sampled residents, Resident (R) 20. In addition, the facility failed to ensure a barrier was used to protect an enhanced barrier precautions (EBP) supply cart from a blood pressure cuff that had not been sanitized.

Inspectors wroteBased on interview, record review, review of the website www.weather.gov, and review of the facility's policies, the facility failed to have an effective system in place to ensure each resident received the electronic monitoring devices to prevent unsafe wandering and elopement, for 1 of 18 sampled residents, Resident (R) 1. Review of R1's Investigation Report revealed R1 was found by State Tested Nurse Aide (STNA) 2 outside the building, approximately 84 feet from the employee entrance/exit, on 08/07/2025 at 11:10 PM as she was getting out of her car from the back parking lot of Household B. Per the report, STNA2 brought R1, who appeared to be confused and was unstable with ambulation, back into the facility to get warm. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policies, the facility failed to ensure each resident had the right to be free from restraint for 1 of 5 sampled residents, Resident (R) 15. On 01/13/2025 at approximately 2:00 PM, a Dining Aide (DA) 1 tied a washcloth around one wheel of R15's wheelchair. Activity Assistant 2 saw R15 on the floor around 3:00 PM. At that time, Activity Assistant 2 notified State Trained Nurse Aide/Kentucky Medical Aide (STNA/KMA) 14 who was in the hall and STNA15. The facility provided an acceptable Plan of Correction (POC) on 01/31/2025 alleging past noncompliance. The State Survey Agency (SSA) survey team validated the deficient practice was corrected on 02/01/2025, following the facility's implementation of the acceptable POC and before the start of the survey.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to implement the abuse policy for 1 of 5 sampled residents, Resident (R) 15. A Dining Aide (DA) 1 tied a washcloth around one wheel of R15's wheelchair around 2:00 PM on 01/13/2025. State Trained Nurse Aide (STNA) 13 witnessed DA1 tie the washcloth to the wheel of R15's wheelchair, but failed to report the incident, and R15 fell from her wheelchair. The facility provided an acceptable Plan of Correction (POC) on 01/31/2025 alleging past noncompliance. The State Survey Agency (SSA) survey team validated the deficient practice was corrected on 02/01/2025, following the facility's implementation of the acceptable POC and before the start of the survey.

Inspectors wroteBased on interview, record review, and review of the facility's policy, it was determined the facility failed to notify the resident's physician of a significant change in the resident's physical status for 2 of 11 sampled residents, Resident (R) 2 and R3. 1. On 12/01/2024, in the early hours of the morning, R3 was observed by Registered Nurse (RN) 2 to have a significant change in mental status. Despite this critical finding, RN2 failed to notify the physician about the resident's condition. At 7:00 AM, during the shift change report, RN2 relayed to Licensed Practical Nurse (LPN) 1 that the resident's mental status had deviated from the baseline during the night. However, neither nurse assessed R3 or notified the physician of his change in mental status. At approximately 11:30 AM, R3's family alerted LPN1 that R3 was febrile, unresponsive, and had tremors. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to develop and implement a baseline care plan within 48 hours for each resident that included instructions needed to provide effective and person-centered care of the resident to meet professional standards of quality care for 2 of 11 sampled residents, Resident (R) 2 and R3. 1. On 11/26/2024, the facility admitted R3 with an intrathecal (the space between the spinal cord and the membranes that protect it) pain pump infection, which was being treated with intravenous (IV) antibiotic therapy via a peripherally inserted central catheter (PICC) line. The facility failed to develop a person centered baseline care plan with interventions to address R3's infection, antibiotic therapy, care of the PICC line, or physician notification for worsening condition. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to promptly identify and intervene with a significant change in a resident's condition, for the resident to receive treatment and care in accordance with professional standards of practice for 1 of 11 sampled residents, Resident (R) 3. R3 was admitted to the facility on [DATE] with diagnoses to include post-surgical infection of the intrathecal (the space between the spinal cord and the membranes that protect it) pain pump. The resident was to receive two weeks of intravenous (IV) antibiotic therapy by a peripherally inserted central catheter (PICC) line. However, the resident did not receive four of those ordered doses. In addition, the MAR revealed the physician ordered metronidazole (an antibiotic) to be administered orally every eight hours, but R3 did not receive five of those doses. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to have an effective system in place to ensure residents were free from significant medication errors for 1 of 2 sampled residents receiving intravenous (IV) antibiotic therapy, Resident (R) 3. On 11/26/2024, the facility admitted R3 with diagnoses to include post laminectomy syndrome (chronic pain following back surgery; a laminectomy was removing part or all of the bony arch that covered the spinal cord) and post-surgical infection of the intrathecal (the space between the spinal cord and the membranes that protect it) pain pump. The resident was scheduled to receive two weeks of intravenous (IV) antibiotic therapy while at the facility. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policies, the facility failed to provide services to prevent pressure ulcers for 1 of 11 sampled residents, Resident (R) 2. On 10/18/2024 an unstageable wound to R2's left bottom heel was found by Physical Therapy (PT) staff. The nursing staff was notified; however, they failed to put interventions in place to care for the wound and prevent further worsening. In addition, the facility failed to include interventions to address R2's need to ensure pressure off-loading boots were on the resident and to off-load the wound while in the bed or up in the wheelchair.

Inspectors wroteBased on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, review of the manufacturer's instructions for use, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 11 sampled residents, Residents (R) 4 and R8. 1. Observation on 12/12/2024 of R4's room revealed the resident was under contact isolation precautions. However, staff was observed in the room without wearing the appropriate personal protective equipment (PPE). Further observation on 12/12/2024 revealed another staff member entered R4's room and did not don (put on) PPE. 2. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the resident's right to privacy was honored for 1 of 11 sampled residents, Resident (R) 8. On 12/18/2024, Licensed Practical Nurse (LPN) 1 lifted R8's shirt and exposed her abdomen while she administered an insulin injection to the resident. R8 was seated at a dining table with three other residents eating lunch.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure drugs and biologicals were stored according to professional standards for 1 of 3 medication carts where an opened pharmacy delivery tote with medications was left unattended.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promoted the maintenance or enhancement of his/her quality of life. The facility failed to ensure residents had a right to communicate with and had access to persons and services inside and outside the facility for 2 of 22 sampled and supplemental residents, Resident (R) 7 and R10. R7's representative and R10's representative stated they were unsuccessful when they attempted multiple times to communicate with the facility via telephone.

Inspectors wroteBased on interview, record review, and review of the facility's policies, the facility failed to ensure each resident had the right to be informed of and participate in his or her treatment for 1 of 22 sampled and supplemental residents, Resident (R) 10. Staff refused to administer a COVID-19 test to R10 when requested by the resident.

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to ensure that the resident's medical record included documentation that indicated the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal for 1 of 5 sampled residents, Resident (R) 43. A review of R43's immunization record revealed the absence of documentation confirming the administration or refusal of the influenza vaccine for 2023-2024.

Inspectors wroteBased on observation, interview, record review and review of the facility's policies, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Observations of meal service on 10/22/19 and 10/23/19 revealed staff failed to perform proper hand hygiene and gloving technique during set up of silverware and glasses prior to serving resident's meal. Further observations revealed staff failed to perform proper hand hygiene while serving resident's meals and were observed touching residents and the serving bar numerous times during the meal service without washing or sanitizing hands. [...]

Inspectors wroteBased on observation, interview, and review of the facility's Policy, it was determined the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized work area. Observations during the survey period and interviews with staff revealed that not all staff members were equipped with the necessary means to be alerted if a resident call light was activated.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality, for two (2) of twenty-four (24) sampled residents (Resident #49 and Resident #53). Observations on 10/22/19, 10/23/19, and 10/24/19 revealed Resident #49 with catheter drainage bag and catheter tubing fully exposed while in commons area of his/her household and during other activities. Observations on 10/24/19 revealed Resident #53 with his/her name printed on outside of his/her non-skid socks. Further observations revealed student at facility identified Resident #53 by name, by observing resident's name located on top of his/her sock.

Inspectors wroteBased on observation, interview, record review, and review of the facility's Policy, it was determined the facility failed to develop and implement a comprehensive person-centered care plan consistent with the resident rights that included measurable objectives and timeframes to meet resident's medical, nursing, mental and psychosocial needs, and included resident goals and desired outcomes and preferences. The facility failed to develop a comprehensive care plan for residents with pressure ulcers for one (1) of twenty-four (24) sampled residents, (Resident #49). Resident #49 had pressure ulcers of the bilateral heels, left buttock and sacral region. However, the facility failed to develop an interdisciplinary care plan related to being at risk for skin breakdown/pressure or actual skin breakdown for pressure wounds to the sacral region, right heel, left heel or buttocks.

Inspectors wroteBased on interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to ensure the Comprehensive Care Plan (CCP) was reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care for one (1) of twenty-four (24) sampled residents (Resident # 53). [...]