A list of the most recent deficiencies for Madonna Manor Nursing Home. 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? |
|---|---|---|---|---|
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-28 | 2024-01-19 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-06 | 2023-09-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-06 | 2023-09-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-19 | 2023-08-28 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-07-19 | 2023-08-16 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-07-19 | 2023-08-16 | 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 | 2023-07-19 | 2023-08-16 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-07-19 | 2023-08-16 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-07-19 | 2023-08-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-19 | 2023-08-16 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-07-19 | 2023-08-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-07-19 | 2023-08-16 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-07-19 | 2023-08-16 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-12-11 | 2020-01-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-12-11 | 2020-01-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-11 | 2020-01-20 | 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 | 2019-12-11 | 2020-01-20 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2019-12-11 | 2020-01-20 | N |
| Provide activities to meet all resident's needs. | Health | 2019-12-11 | 2020-01-20 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2019-12-11 | 2020-01-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-12-11 | 2020-01-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-12-11 | 2020-01-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-12-11 | 2020-01-20 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-12-11 | 2020-01-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-09-18 | 2018-10-11 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-09-18 | 2018-10-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-09-18 | 2018-10-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-09-18 | 2018-10-11 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2018-09-18 | 2018-10-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-18 | 2018-10-11 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-09-18 | 2018-10-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-09-18 | 2018-10-11 | N |
| Provide or obtain dental services for each resident. | Health | 2018-09-18 | 2018-10-11 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-09-18 | 2018-10-11 | N |
