Madonna Manor Nursing Home

In the surveyor’s words

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

• Actual harm, isolatedF580Aug 21, 2024

  Based 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. Findings include: Review of the facility's policy titled Weight Loss Policy, dated as reviewed 2/2024, indicated but was not limited to the following: - all confirmed weight loss of 5 pounds (lbs.) or more within one month is reported to the dietician, the weight information is recorded in the chart - staff must also report any continuing trends of monthly weight loss, even if it is below 5 lbs. […]

• Actual harm, isolatedF692Aug 21, 2024

  Based 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. Findings include: Review of the facility's policy titled Weight Loss Policy, dated as reviewed 2/2024, indicated but was not limited to the following: - all confirmed weight loss of 5 pounds (lbs.) or more within one month is reported to the dietician, the weight information is recorded in the chart - staff must also report any continuing trends of monthly… […]

• Actual harm, isolatedF656Sep 6, 2023

  Based 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. […]

• Actual harm, isolatedF689Sep 6, 2023

  Based 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. […]

• Actual harm, isolatedF689Jul 19, 2023

  Based 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. Findings include: 1. […]