A list of the most recent deficiencies for Madonna Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-04 | 2021-04-13 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-03-04 | 2021-04-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-03-04 | 2021-04-13 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-03-04 | 2021-04-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-10-25 | 2019-12-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-25 | 2019-12-13 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-10-25 | 2019-12-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-25 | 2019-12-13 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2019-10-25 | 2019-12-13 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2019-10-22 | 2019-11-22 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-10-22 | 2019-11-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-10-22 | 2019-11-22 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2019-10-22 | 2019-11-22 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-09-14 | 2018-10-20 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2018-09-14 | 2018-10-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2018-09-14 | 2018-10-20 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2018-09-14 | 2018-10-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-09-14 | 2018-10-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-09-11 | 2018-10-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-09-11 | 2018-10-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-12-07 | 2018-01-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2017-12-07 | 2018-01-16 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2017-12-07 | 2018-01-16 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2017-12-05 | 2018-01-16 | N |
| Ensure that laboratories employing quantities of flammable, combustible, or hazardous materials have fire resistant walls and automatic sprinkler system. | Fire Safety | 2017-12-05 | 2018-01-16 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2017-12-05 | 2018-01-16 | N |
