Madonna Manor

In the surveyor’s words

From the most serious findings on record at Madonna Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 23, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF580Jan 3, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF655Jan 3, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF684Jan 3, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF760Jan 3, 2025

  Based 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. […]