Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Madonna Manor during CMS and state inspections, most recent first.
Food Storage and Sanitation Deficiencies in Kitchen: Surveyors observed cleaning cloths left on food prep counters instead of in sanitizer buckets, open trash cans in the food production area, and numerous dry storage items that were unlabeled, undated, or expired. Findings included opened cereal, marshmallows, gelatin mixes, walnuts, vanilla wafers with a hole in the package, gravy mixes, powdered sugar, pasta, cornstarch, chip bags, cake mixes, and an expired cornmeal package. The Dietary Manager, DON, and Administrator all acknowledged the facility’s food service expectations for proper dating, labeling, trash receptacle use, and cloth storage.
The facility failed to follow infection control practices when an LPN entered a resident’s Contact Isolation room without the required gown or gloves, handled items in the room, and then touched unit surfaces before hand hygiene. The facility also failed to protect an EBP supply cart when an RN placed a BP wrist cuff on top of the cart without a barrier before disinfecting it. The resident involved had ESBL in the urine and moderate cognitive impairment, and the facility’s own policies required hand hygiene, PPE use, and protection of reusable items from contamination.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as identified by surveyors.
A resident with moderate cognitive impairment was improperly restrained by a Dining Aide who tied a washcloth to the wheel of the resident's wheelchair to prevent wandering. This action was witnessed by a STNA who did not report it. The facility's policy prohibits the use of physical restraints unless medically necessary, and the Administrator confirmed that such restraint is not a standard for quality care.
A resident with dementia fell from her wheelchair after a Dining Aide tied a washcloth to the wheel, witnessed by an STNA who failed to report the incident. The resident, assessed as moderately cognitively impaired, was at risk for falls. The facility's policy required immediate reporting of such incidents, which was not followed, leading to a violation of the abuse policy.
The facility failed to notify the physician of significant changes in the condition of two residents, leading to serious health consequences. One resident experienced a significant change in mental status, which was not reported, resulting in a critical emergency department admission. Another resident developed an unstageable wound that worsened due to delayed notification and treatment. Interviews revealed a lack of adherence to the facility's policy for notifying physicians of changes in residents' conditions.
The facility failed to develop timely baseline care plans for two residents, leading to inadequate care. One resident with an infection and PICC line did not have a care plan addressing these needs, resulting in a transfer to the ED with sepsis. Another resident at risk for pressure injuries developed a severe heel wound due to a lack of interventions in the care plan. Staff interviews revealed confusion about responsibilities for initiating and revising care plans.
A resident with a post-surgical infection did not receive several doses of prescribed antibiotics due to the facility's failure to administer them as ordered. Despite a significant change in the resident's mental status being observed, neither the RN nor the LPN conducted an assessment or notified the physician. The resident's family later found the resident unresponsive and requested an emergency transfer to the hospital, where the resident was admitted with life-threatening conditions.
A resident admitted with post-surgical infection did not receive several doses of prescribed antibiotics, cefepime and metronidazole, as ordered. The resident's family found them unresponsive and febrile, leading to a hospital transfer where they were diagnosed with sepsis and atrial fibrillation. Interviews revealed that the LPN fell behind on medication administration, and there was no formal documentation of medication audits.
A resident at an LTC facility developed an unstageable pressure ulcer due to the facility's failure to implement necessary interventions and conduct regular skin assessments. Despite being at risk, the resident did not receive adequate pressure off-loading measures, and discrepancies in documentation further delayed appropriate care.
The facility failed to maintain an effective infection prevention and control program, as staff did not adhere to PPE protocols and proper cleaning of shared medical equipment. An APRN and RN entered a contact isolation room without wearing gowns and gloves, while an LPN mishandled a contaminated glucometer by not following cleaning protocols. Despite training, staff did not consistently implement infection control practices.
A resident's privacy was compromised when an LPN administered an insulin injection at a dining table in view of other residents, contrary to facility policy. The resident had consented to the procedure to avoid her meal getting cold, but the facility's protocol requires private administration of medical treatments to ensure dignity and privacy.
A facility failed to store medications according to professional standards when a pharmacy delivery tote was left unattended and unsecured on a medication cart. The tote contained various medications, including albuterol, IV fluids, and heparin, and was found in a public area. Interviews with staff confirmed that medications should be stored in locked compartments immediately upon receipt, highlighting a lapse in following facility policy.
A resident in an LTC facility was denied a COVID-19 test despite exhibiting symptoms and a family member's request. The facility's policy allowed for testing upon request, but staff refused, citing no positive cases in the facility. Interviews revealed a lack of adherence to the facility's COVID-19 testing guidelines.
A facility failed to document whether a resident with COPD and Alzheimer's received or refused the influenza vaccine for 2023-2024. Despite policies requiring documentation, the resident's immunization record lacked this information. Interviews with the IP Nurse and DON confirmed that education and consent were provided, but documentation was missing. The Administrator expected records to reflect immunization status.
The facility failed to ensure effective communication with residents' families, leading to distress and concern. Two residents' family members reported being unable to reach the facility due to unanswered calls and full voicemail boxes. Staff interviews revealed systemic issues with the phone system, including a lack of responsibility for checking messages and informing families of updated contact numbers.
Food Storage and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to store and prepare food under sanitary conditions. During a kitchen tour, surveyors observed two cleaning cloths lying on food production counters instead of being stored in sanitizer buckets, an open trash can in the food production area, and multiple dry storage food items that were not labeled or dated. Items observed included opened marshmallows with no date, dry cereal packages with no date or label, gelatin mixes with no date, walnuts taped closed without a date or label, a clear package of vanilla wafers with no date or label and a visible hole in the package, gravy mixes with no date, and powdered sugar packages with no label or date. Additional observations showed the same concerns continued on later visits. Surveyors again found food items in dry storage that were not labeled or dated, including a vanilla wafer package with a visible hole and a wafer fallen onto the shelf, a cleaning cloth on the counter instead of in the sanitizer bucket, and two open trash cans in the food production area, one placed near the stand mixer during food production. In dry storage on a later date, surveyors observed multiple undated items, including an expired cornmeal package with a use-by date of 04/22/2023, opened and undated pasta, cornstarch packages, gravy mix packages, powdered sugar packages, chip bags, and cake mixes. The Dietary Manager stated dry storage food products needed to be dated if taken out of the box, and the DON and Administrator stated staff should follow food service policies regarding trash receptacles, labeling and dating of food, and storage of cleaning cloths in sanitizing solution.
Infection Control Failures With Contact Isolation and Equipment Handling
Penalty
Summary
The facility failed to maintain its infection prevention and control program when staff involved in direct resident contact did not follow required hand hygiene procedures and personal protective equipment (PPE) requirements for a resident on Contact Isolation for ESBL in the urine. The resident had been admitted with diagnoses including cognitive communication disorder, chronic kidney disease, and acute kidney failure, and the quarterly MDS showed a BIMS score of 12, occasional bladder incontinence, always incontinent bowel, and need for partial/moderate assistance with toileting hygiene and bathing. During observation, a staff member entered the resident’s room while the Contact Isolation sign was posted and PPE was available outside the room, but she did not don a gown or gloves before or while in the room. She stood at the bedside, picked up and held a cup, exited the room carrying the cup, placed it in a plastic bin in the kitchenette area, then touched the medication cart keyboard and used hand sanitizer. In interview, the staff member stated she knew the resident was on Contact Isolation for ESBL in the urine, acknowledged she should have worn gloves and a gown before entering, and stated that because she had not worn gloves she should have washed her hands with soap and water. She also stated she had received annual training but had been busy and forgot to follow the guidelines. The facility also failed to ensure a barrier was used to protect an enhanced barrier precautions supply cart from a blood pressure wrist cuff that had not been sanitized. During observation, a nurse exited a room with a BP wrist cuff, placed it on top of the EBP box without a barrier, and then used a disinfectant wipe to sanitize the cuff while talking on his phone. The nurse stated a barrier was needed on top of the EBP box to prevent cross contamination between residents. The DON stated the BP cuff should be cleaned between residents and a barrier put down if setting the cuff on top of the EBP box, and the IP stated staff were expected to follow the facility’s handwashing and PPE policies as written.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified by surveyors based on observations or events that indicated the environment posed risks for accidents and that supervision was insufficient to prevent such incidents. No additional details about specific residents, their medical history, or the exact nature of the hazards or accidents were provided in the report.
Resident Restrained with Washcloth in Wheelchair
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as evidenced by an incident involving a Dining Aide (DA) who tied a washcloth around one wheel of a resident's wheelchair. This action was taken to prevent the resident from wandering around the facility. The resident, identified as having moderate cognitive impairment and a history of dementia, was found on the floor by an Activity Assistant, which led to the discovery of the restraint. The resident, who was admitted to the facility with diagnoses including dementia and cognitive communication deficit, was assessed to be ambulatory and capable of self-propelling in a manual wheelchair. Despite this, the DA's action of tying a washcloth to the wheelchair wheel was witnessed by a State Trained Nurse Aide (STNA), who failed to report the incident. The facility's policy clearly states that residents have the right to be free from physical restraints unless required for medical treatment, and the tying of the washcloth was not in line with this policy. The Administrator was informed of the incident after the resident was found on the floor. An investigation was initiated, revealing that the washcloth was used as a restraint, which is not a standard for quality care. The Administrator confirmed that the use of a washcloth to restrict a resident's movement is considered a form of physical restraint, which is against the facility's policy and residents' rights.
Failure to Implement Abuse Policy Leads to Resident Fall
Penalty
Summary
The facility failed to implement its abuse policy for one of the sampled residents, identified as R15. A Dining Aide (DA1) tied a washcloth around one wheel of R15's wheelchair, which was witnessed by a State Trained Nurse Aide (STNA13) who did not report the incident. This action led to R15 falling from her wheelchair. The facility's policy required staff to immediately report any incidents of abuse, neglect, or mistreatment to the Administrator, who would then report to the appropriate agencies. However, STNA13 did not report the incident, which was a violation of the facility's policy. R15 was admitted to the facility with diagnoses of dementia, cognitive communication deficit, and disorientation. The resident was assessed to be moderately cognitively impaired and used a manual wheelchair for mobility. R15's Comprehensive Care Plan indicated a risk for falls due to impaired mobility and other health conditions. Despite these known risks, the incident occurred when DA1 tied a washcloth to the wheelchair, making it stationary and leading to R15's fall. The incident was discovered when Nurse 8 was called to assess R15, who was found lying on the floor with no physical injuries. During interviews, it was revealed that STNA13 was unsure if the washcloth constituted a restraint and did not report it. The Administrator confirmed that tying a washcloth to a wheelchair to restrict movement was a form of physical restraint and not in line with quality care standards. The failure to report the incident by STNA13 conflicted with the facility's policy on reporting abuse.
Failure to Notify Physician of Change in Condition
Penalty
Summary
The facility failed to notify the physician of a significant change in the physical status of two residents, leading to serious health consequences. For one resident, a significant change in mental status was observed by a registered nurse, but the physician was not notified. The resident's condition worsened, and the family eventually found the resident unresponsive and requested emergency medical services. The resident was admitted to the emergency department with altered mental status, sepsis, and atrial fibrillation with rapid ventricular response. In another case, a physical therapist discovered an unstageable wound on a resident's heel, but the nursing staff did not notify the physician immediately. The wound worsened over several days, and the resident experienced pain and difficulty with mobility. The wound care physician was eventually notified and provided new treatment orders, but the delay in notification and treatment likely contributed to the wound's deterioration. Interviews with staff and family members revealed a lack of adherence to the facility's policy for notifying physicians of changes in residents' conditions. The nursing staff failed to assess and document the residents' conditions promptly, and there was a breakdown in communication between the nursing staff and other healthcare providers. This failure to follow established procedures put the residents at risk for serious harm.
Removal Plan
- An Ad Hoc QAPI meeting was held with DON, Medical Director and ED discussing IJ regarding Notification of Changes for Medical Director input.
- Notification of Changes policy was reviewed by the Director of Clinical Risk Management.
- The Director of Clinical Risk Manager provided education for the Director of Nursing, Executive Director and Nurse Managers regarding the Notification of Changes policy.
- The Executive Director, Corporate Clinical Leadership Team, Director of Clinical Risk, DON discussed the Notification of Changes policy and the plan for the abatement.
- Education was provided by Nurse Managers for all nurses and KMAs regarding Notification of Changes policy. Agency nurses were educated prior to their shift by DON/Nurse Managers. 25/28 completed = 93%, 1 nurse on leave will be educated by DON/Nurse Managers prior to her return to work., 2 staff still to complete prior to their next shift.
- All nurses and KMAs who are hired will be educated by the DON/Nurse Managers regarding the Notification of Changes policy prior to working.
- All progress notes were reviewed by DON/Nurse Manager for changes in condition of identified residents and proper notification of MD and Responsible Party as appropriate.
- Information was given to STNAs, housekeepers and dietary staff regarding what to do when you notice a change in a residents' condition. Information sent by ED via text.
- The 24 hour report sheet and the 24 hour summary in Point Click Care (PCC) will be reviewed by DON/Nurse Manager daily for appropriate notification of changes in the morning Clinical Meeting.
- DON/Nurse Managers administer quizzes to nurses and KMAs regarding Notification of Changes in Condition and report results to QAPI team. If a question is missed, DON/Nurse Managers will educate the nurse immediately and document the education.
- DON reported audit results regarding notification of changes missed at the QAPI meeting and will continue to report audit results and how findings were resolved to QAPI weekly for 4 weeks then every other week until substantial compliance is achieved.
- QAPI meeting was attended by Medical Director, Nurse Practitioner, ED, DON, Diet Tech, Nurse Managers, IP Nurse, Social Worker designee, Director of Facilities, Business Office Manager, MOS nurse, Director of Therapy and Life Enrichment Director. IJ abatement plan audits, results, and follow up were discussed.
- Next QAPI meeting scheduled.
Failure to Implement Timely Baseline Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours for two residents, R2 and R3, which resulted in deficiencies in providing effective and person-centered care. R3 was admitted with an intrathecal pain pump infection and was receiving intravenous antibiotic therapy via a PICC line. However, the facility did not create a baseline care plan addressing R3's infection, antibiotic therapy, PICC line care, or procedures for physician notification in case of a worsening condition. This oversight led to R3 being transferred to the emergency department with an altered mental status, sepsis, and atrial fibrillation with rapid ventricular response. R2 was admitted with a risk for developing pressure injuries, and an unstageable wound on the left heel was identified by the physical therapy staff. Despite this, R2's baseline care plan did not address the existing skin issues or include interventions to prevent further deterioration. The wound worsened significantly over a few days, leading to pain and the need for treatment at another facility. The facility's failure to revise R2's care plan to include necessary interventions for skin breakdown contributed to the resident's decline. Interviews with facility staff revealed a lack of clarity and responsibility regarding the initiation and revision of baseline care plans. LPN1 was unaware of her responsibility to initiate care plans, and the MDS Nurse indicated that care plans were sometimes delayed due to admissions occurring during off-hours. The Interim Director of Nursing and other staff members acknowledged the importance of including health and safety concerns in baseline care plans but could not identify why the care plans for R2 and R3 were incomplete.
Removal Plan
- An Ad Hoc QAPI meeting was held with DON, Medical Director and ED discussing IJ regarding Baseline Care Plans for Medical Director input.
- The Director of Clinical Risk Management educated the DON and Nurse Managers on the Baseline Care Plan Policy.
- The Executive Director, Corporate Clinical Leadership Team, Director of Clinical Risk, DON discussed the Baseline Care Plan policy and the plan for the abatement.
- The Director of Clinical Reimbursement and the MDS nurse audited all baseline care plans for completion and accuracy. If the baseline care plan was missed, comprehensive care plans from admissions have been completed.
- Education was provided by DON/Nurse Managers for all nurses and KMAs regarding the Baseline Care Plan policy. Agency nurses are educated prior to their shift by the DON/Nurse Managers. 100% of nurses educated (1 nurse on leave will be educated prior to returning to work by the DON/Nurse Managers).
- DON/Nurse Managers administer quizzes to nurses and KMAs regarding Baseline Care Plans and report results to the QAPI team weekly. Any nurses/KMAs not receiving a 100% correct will receive 1:1 education provided by the DON/Nurse Managers.
- DON/Nurse Managers will audit Baseline Care Plan daily 7 days per week in morning clinical meetings. 100% Baseline Care Plans have been completed per policy.
- DON/Nurse Managers reported results of the audit of baseline care plans, issues that needed resolution and how resolution was achieved to the QAPI committee and will continue to report to QAPI weekly for 4 weeks and then every other week until substantial compliance is achieved.
- QAPI meeting was attended by Medical Director, Nurse Practitioner, ED, DON, Diet Tech, Nurse Manager, IP Nurse, Social Worker designee, Director of Facilities, Business Office Manager, MDS nurse, Director of Therapy and Life Enrichment Director. IJ abatement plan audits, results, and follow up were discussed.
- The next QAPI meeting will review Baseline Care Plan completion.
Failure to Administer Medications and Respond to Change in Condition
Penalty
Summary
The facility failed to promptly identify and intervene with a significant change in a resident's condition, leading to a deficiency in providing treatment and care according to professional standards of practice. A resident, identified as R3, was admitted with a post-surgical infection of the intrathecal pain pump and was prescribed a two-week course of intravenous antibiotic therapy via a PICC line. However, the resident missed several doses of the prescribed antibiotics, both intravenous and oral, due to the facility's failure to administer them as ordered. This lapse in medication administration contributed to the resident's deteriorating condition. On a particular morning, a registered nurse observed a significant change in R3's mental status but failed to conduct a thorough assessment or notify the physician. During the shift change, this information was communicated to an LPN, who also did not assess the resident or notify the physician. It was not until the resident's family alerted the staff later that morning that the resident was found to be febrile, unresponsive, and exhibiting tremors. The family requested an emergency transfer to the hospital, where the resident was admitted with life-threatening conditions, including sepsis and atrial fibrillation. The facility's policy required that residents receive care in accordance with professional standards, including timely medication administration and appropriate response to changes in condition. However, the facility failed to adhere to these standards, as evidenced by the lack of documented assessments and the missed doses of antibiotics. The failure to follow established policies and procedures resulted in the resident's hospitalization and critical care admission, highlighting a significant deficiency in the facility's quality of care.
Removal Plan
- An Ad Hoc QAPI meeting was held with DON, Medical Director and ED to discuss quality of care related to Medication Administration, Baseline Care Plans, and Notification of Changes in Resident Condition for Medical Director input.
- Notification of Changes Policy, the Baseline Care Plan Policy and the Medication Administration Policy were reviewed immediately for accuracy by the Director of Clinical Risk Management.
- The Executive Director, Corporate Clinical Team and DON discussed the Notification of Changes in Condition, Medication Administration, and Baseline Care Plan policies and the plan for abatement.
- The Executive Director, Corporate Clinical Team and DON discussed the Provision of Quality Care policy.
- The Director of Clinical Risk Management educated the DON, Nurse Managers and ED regarding Baseline Care Plans, Medication Administration and Notification of Changes in Resident Condition and Provision of Quality Care policies.
- The DON/Nurse Managers provided education for all nurses and KMAs regarding Notification of Changes, Baseline Care Plan, and Medication Administration policies and provisions of the Quality of Care policy prior to their next shift. Agency nurses received education prior to their shift by DON/Nurse Managers. 100% completion of active staff, 1 nurse on leave will be educated by the DON/Nurse Manager prior to returning to work.
- Going forward all newly hired nurses and all agency staff will be educated by the DON/Nurse Managers on the Notification of Changes, Baseline Care Plan, Medication Administration, Provision of Quality Care policies and the Nurse Clinical Binder.
- DON/Nurse Managers completed an audit of all progress notes for changes in condition of identified residents and proper notification of MD and Responsible Party as appropriate.
- STNAs, Housekeepers and Dining staff received information via text regarding: if they notice a change in a residents' condition that they should report it to the nurse immediately.
- Director of Clinical Risk Management/DON audited all missed meds for identified residents using the Medication Administration Audit Report.
- DON notified the Medical Director of results of the Medication Admin Audit report and asked for any new orders. No new orders given. DON notified responsible parties of any current affected residents.
- The Director of Clinical Reimbursement and MDS nurse audited baseline care plans for admissions for completion and accuracy. If incomplete or inaccurate, comprehensive care plans have been completed by the Director of Clinical Reimbursement/MOS nurse.
- In morning clinical meeting- DON/Nurse Managers review 24 hour report sheet and 24 hour summary report in PCC daily for appropriate notification of changes in resident condition. The DON reported results of the audit to the QAPI committee and will continue to report audit results to QAPI weekly for 4 weeks then every other week until substantial compliance is achieved.
- The Medication Admin Audit Report in PCC is completed daily by DON/Nurse Managers. Missed medications will be reported to the MD and responsible party immediately as per policy by the DON/Nurse Manager. Report audit results to QAPI weekly for 4 weeks then every other week until substantial compliance is achieved.
- Nurse Managers provide daily 1:1 Nurse/KMA coaching to ensure medication administration per MD orders and following the nursing process to assure quality care.
- Audit of baseline care plans will be by the DON/Nurse Managers daily with immediate follow up. 100% compliance has been achieved to date. DON reported results to QAPI committee and will continue to report audit results to QAPI weekly for 4 weeks then every other week until substantial compliance is achieved.
- QAPI meeting was attended by Medical Director, Nurse Practitioner, ED, DON, Diet Tech, Nurse Manager, IP Nurse, Social Worker designee, Director of Facilities, Business Office Manager, MOS nurse, Director of Therapy and Life Enrichment Director. IJ abatement plan audits, results, and follow up were discussed.
- Next QAPI meeting scheduled.
Failure to Administer Antibiotics as Ordered
Penalty
Summary
The facility failed to ensure that a resident, identified as R3, was free from significant medication errors during their stay. R3 was admitted with diagnoses including post laminectomy syndrome and a post-surgical infection of the intrathecal pain pump, requiring intravenous antibiotic therapy. However, the facility did not administer several doses of the prescribed antibiotics, cefepime and metronidazole, as ordered by the physician. Specifically, R3 missed four doses of cefepime and five doses of metronidazole, and some doses were administered outside the scheduled time frame, contrary to the facility's medication administration policy. On one occasion, R3's family found the resident febrile, unresponsive, and exhibiting tremors, prompting them to alert a Licensed Practical Nurse (LPN). The LPN had not administered the 9:00 AM dose of IV antibiotics by the time the family raised concerns. R3 was subsequently transferred to the emergency department, where they were diagnosed with an altered mental status, sepsis, and atrial fibrillation with rapid ventricular response. The resident required critical care and was hospitalized for 12 days. Interviews with facility staff, including the LPN, Advanced Practice Registered Nurse (APRN), Medical Director, and others, revealed expectations that medications should be administered as ordered to prevent infection recurrence and ensure resident safety. However, the LPN admitted to falling behind on medication administration due to a busy day and did not seek assistance. The Interim Director of Nursing (IDON) acknowledged that there was no formal documentation of medication administration audits, which contributed to the oversight in ensuring timely and accurate medication delivery.
Removal Plan
- An Ad Hoc QAPI meeting was held with DON, Medical Director and ED discussed IJ regarding Medication Administration for Medical Director input.
- The Corporate Clinical team, VP of Operations, Executive Director and DON discussed the Medication Administration policy and the plan for abatement.
- The Director of Clinical Risk Management reviewed the Medication Administration policy.
- The Director of Clinical Risk Management educated the DON and Nurse Managers regarding the Medication Administration policy.
- The Director of Clinical Risk Management and the DON audited all missed meds using the Medication Admin Audit Report in PCC and communicated with MD and responsible party as needed.
- The DON/Nurse Managers provided education for all nurses and KMAs regarding Medication Administration policy and the Nurse Clinical Binder. Agency Nurses are educated prior to their shift. 100% complete with 1 nurse on leave who will be educated prior to her return to work.
- Nurses were educated by the DON/Nurse Managers on the Nurse Clinical Binder that includes information on Daily Nurse Expectations, pharmacy cut off times, admission/readmission orders, what to do when a medication is unavailable, what to do when someone admits to the facility, what to do when a resident receives new orders, what to do when sending someone to the hospital, what to do when you receive medications from the pharmacy and Medication Administration Special Considerations. Education was initially completed by the DON at the Monthly All Staff Clinical Meeting. The DON/Nurse Managers started referencing the Nurse Clinical Binder as education on step by step guides for nurses and KMAs.
- DON/Nurse Managers administer quizzes to nurses and KMAs regarding Medication Administration. DON/Nurse Managers follow up with Nurse/KMA if a question is missed and reports results to QAPI team.
- DON/Nurse Manager completes audit using Medication Admin Audit Report in PCC. DON/ Nurse Managers address issues immediately with appropriate nurse or KMA and assures follow up regarding notification policy.
- Nurse Managers provided 1:1 Nurse/KMA coaching to ensure medication administration per MD orders.
- DON/Nurse Managers compare the hospital discharge summary to the MD orders in PCC for all new admissions, to assure accuracy and timeliness of medication administration. Results of the audits will be reported to the QAPI committee until substantial compliance is achieved.
- DON/Nurse Manager reported results of audits, follow up, and trends to QAPI committee and will continue to report data to QAPI until we are in substantial compliance.
- QAPI meeting was attended by Medical Director, Nurse Practitioner, ED, DON, Diet Tech, Nurse Manager, IP Nurse, Social Worker designee, Director of Facilities, Business Office Manager, MDS nurse, Director of Therapy and Life Enrichment Director. IP abatement plan audits, results, and follow up were discussed.
- The next QAPI meeting is scheduled.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate pressure ulcer prevention and care for a resident, identified as R2, who was admitted with a history of idiopathic hydrocephalus, peripheral vascular disease, and atherosclerosis with ulceration. Upon admission, R2 was assessed as being at risk for pressure ulcer development, yet the facility did not implement necessary interventions to prevent pressure ulcers or manage existing ones. Despite having a baseline care plan that included some interventions, the facility did not ensure the use of pressure off-loading boots or off-load the wound while the resident was in bed or a wheelchair. The deficiency was further compounded by the facility's failure to conduct regular skin assessments as ordered. Although there was an order for weekly skin assessments, only one was documented during R2's stay. The facility's records also showed discrepancies in the documentation of R2's skin condition, with some notes indicating intact skin while others noted skin breakdown. The nursing staff did not update the treatment administration record or baseline care plan to reflect the necessary interventions for R2's pressure ulcer care, despite recommendations from the Advanced Practice Registered Nurse and the Physical Therapy staff. Interviews with staff and family members revealed a lack of communication and adherence to care protocols. The family expressed concerns that their requests for pressure off-loading were not honored, and the former Director of Nursing could not recall critical details about the timeline of the wound's development and treatment. The Infection Preventionist/Wound Care Nurse and the Wound Care Physician were not informed promptly about the wound, leading to delays in appropriate treatment. This lack of timely intervention and documentation contributed to the development of an unstageable pressure ulcer on R2's left heel, which was not present upon admission.
Infection Control Deficiencies in PPE Use and Equipment Cleaning
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observations of staff not adhering to proper infection control protocols. In one instance, a resident under contact isolation precautions was visited by an Advanced Practice Registered Nurse (APRN) and a Registered Nurse (RN) who both failed to wear the required personal protective equipment (PPE) such as gowns and gloves. The APRN was observed sitting on the resident's unmade bed, which she later acknowledged was inappropriate and could facilitate the spread of infection. Both the APRN and RN admitted to knowing the facility's policy on PPE use but did not adhere to it during their interactions with the resident. Another deficiency was observed with a Licensed Practical Nurse (LPN) who mishandled a contaminated glucometer after performing a blood glucose fingerstick on a resident. The LPN was seen carrying the glucometer without gloves and placing it on a medication cart without a protective barrier. Despite being aware of the correct cleaning protocol, the LPN failed to clean the glucometer immediately and did not follow the manufacturer's instructions for the required dwell time for disinfection. This lapse in protocol was repeated on a separate occasion, indicating a pattern of non-compliance with infection control procedures. Interviews with the Infection Preventionist/Wound Care Nurse (IP/WCN) and the Interim Director of Nursing (IDON) revealed that staff had received training on infection prevention and control practices, including the use of PPE and cleaning protocols. However, there was no documentation of staff audits to ensure compliance with these practices. The Executive Director also expressed the expectation that staff adhere to the facility's infection control policies to prevent the spread of infection, yet the observed deficiencies indicate a failure to consistently implement these protocols.
Failure to Ensure Resident Privacy During Medical Procedure
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident, identified as R8, during a medical procedure. On 12/18/2024, an LPN administered an insulin injection to R8 at a dining table in the presence of other residents. R8, who was cognitively intact with a BIMS score of 15, had consented to receive the injection at the table to avoid her meal getting cold. However, this action was against the facility's policy, which mandates that medical treatments be conducted privately to respect residents' rights to privacy and dignity. The LPN admitted to not providing privacy during the procedure and acknowledged that she did not consult other residents about their comfort with the situation. The interim Director of Nursing and the Executive Director both confirmed that the facility's protocol requires medication administration to occur privately, regardless of resident consent, to maintain dignity and privacy. The Director of Clinical Risk Management stated that the facility adheres to CMS nursing care standards, emphasizing the importance of following established policies to ensure appropriate care.
Unattended Pharmacy Delivery Tote Leads to Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored according to professional standards, as evidenced by an incident involving an unattended and unsecured pharmacy delivery tote. During an observation, a medication cart in Household B Hall was found with an opened pharmacy delivery tote containing various medications, including albuterol inhalation solution packets, IV fluid bags, heparin flush injections, and IV ceftriaxone bags. The tote was left unattended in a public area where residents and staff were passing by, contrary to the facility's policy that requires medications to be stored in locked compartments accessible only to authorized personnel. Interviews with facility staff, including an LPN, an RN, the Interim Director of Nursing, and the Executive Director, confirmed that the medications should have been stored in the medication room or the designated medication cart immediately upon receipt from the pharmacy. The LPN admitted to leaving the tote unattended while administering medication to a resident, and both the RN and the Interim Director of Nursing acknowledged the potential safety risks posed by leaving medications unsecured. The Executive Director emphasized the expectation that staff adhere to the facility's policy to ensure the safe and appropriate care of residents.
Failure to Administer COVID-19 Test Upon Request
Penalty
Summary
The facility failed to ensure that a resident, identified as R10, was informed of and able to participate in their treatment, specifically regarding COVID-19 testing. Despite the facility's policy allowing residents to request COVID-19 tests, staff refused to administer a test to R10 when requested by the resident's family member. The facility's policy stated that anyone with even mild symptoms should receive a viral test, but staff denied the request, claiming there were no positive COVID cases in the facility. This refusal occurred despite R10 exhibiting symptoms such as a slight cough and runny nose. Interviews with family members and staff revealed that the facility did not follow its own policies regarding COVID-19 testing. The Infection Preventionist Nurse and the Director of Nursing both stated that residents could request a COVID test at any time and that there was no reason to deny such a request. However, the family member's request for a test was not fulfilled, and there was no documentation of COVID testing or results in R10's records. This incident highlights a failure in communication and adherence to established protocols, resulting in the resident not receiving the requested COVID-19 test.
Deficiency in Documenting Influenza Immunization
Penalty
Summary
The facility failed to ensure that a resident's medical record included documentation indicating whether the resident received or refused the influenza immunization for the 2023-2024 season. This deficiency was identified for one of the five sampled residents, who was admitted with chronic obstructive pulmonary disease (COPD) and Alzheimer's disease. The resident's immunization record lacked evidence of the administration or refusal of the influenza vaccine, despite the facility's policy requiring such documentation. Interviews with the Infection Preventionist (IP) Nurse and the Director of Nursing (DON) revealed that residents were provided with educational information about vaccines and that consent was obtained before administration. However, the documentation of this process was missing in the resident's chart. The Administrator confirmed the expectation that medical records should reflect either the administration or refusal of immunizations, in line with the facility's infection prevention guidelines.
Communication Failures in Resident Care
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity, particularly in maintaining communication with family members. Two residents, R7 and R10, were involved in incidents where their family members were unable to reach the facility via telephone. R7's family member reported multiple unsuccessful attempts to contact the facility to check on the resident's condition after a COVID diagnosis, only to find out later that the facility had changed its phone numbers without notifying them. Similarly, R10's family member experienced difficulties reaching the facility, leading to concerns about the resident's well-being. Interviews with staff revealed systemic issues with the facility's phone system. The DON and other staff members acknowledged that calls were often not answered, went straight to voicemail, or were not returned due to full mailboxes. The facility's policy allowed for calls to be forwarded to staff cell phones after hours, but there was no designated person responsible for checking and returning messages. This lack of communication was further compounded by the fact that family members were not informed of updated contact numbers, leading to confusion and distress. The facility's failure to maintain effective communication channels was evident during the surveyor's attempt to contact the facility, which also resulted in a full voicemail box. Interviews with the receptionist and other staff highlighted a lack of clarity and responsibility in handling incoming calls, especially after hours. The administrator confirmed that the facility had sent updated phone numbers to residents and families, but the ongoing communication issues suggested that this information was not effectively disseminated or utilized.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 874 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Villa Hills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brookside Healthcare Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Village Care Center | 2.6 mi | ★★★★★ | 7 | 0 |
| Villaspring Of Erlanger | 3.6 mi | ★★★★★ | 5 | 0 |
| Bayley Place | 3.8 mi | ★★★★★ | 11 | 0 |
| Ivy Woods Healthcare Center. | 3.9 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.