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🔎 Madonna Manor Nursing Home

Inspection Results


Inspection Overview

Madonna Manor Nursing Home has been cited for a total of 64 deficiencies since we began saving each survey.

In Massachusetts, the average facility has **46.34 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2024-12-02
Correction Date: 2024-12-16
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Survey Date: 2024-08-21
Correction Date: 2024-09-10
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to organize and participate in resident/family groups in the facility.

Survey Date: 2024-08-21
Correction Date: 2024-09-10
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: G

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2024-08-21
Correction Date: 2024-09-10
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Survey Date: 2024-08-21
Correction Date: 2024-09-10
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Survey Date: 2024-08-21
Correction Date: 2024-09-10
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2024-08-21
Correction Date: 2024-09-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: G

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2024-08-21
Correction Date: 2024-09-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2024-08-21
Correction Date: 2024-09-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2024-08-21
Correction Date: 2024-09-10
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: E

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2023-12-28
Correction Date: 2024-01-19
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: G

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2023-09-06
Correction Date: 2023-09-27
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2023-09-06
Correction Date: 2023-09-27
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Keep residents' personal and medical records private and confidential.

Survey Date: 2023-07-19
Correction Date: 2023-08-16
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2023-07-19
Correction Date: 2023-08-16
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2023-07-19
Correction Date: 2023-08-16
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Assist a resident in gaining access to vision and hearing services.

Survey Date: 2023-07-19
Correction Date: 2023-08-16
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2023-07-19
Correction Date: 2023-08-16
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2023-07-19
Correction Date: 2023-08-16
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey Date: 2023-07-19
Correction Date: 2023-08-16
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2023-07-19
Correction Date: 2023-08-16
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2023-07-19
Correction Date: 2023-08-16
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2023-07-19
Correction Date: 2023-08-28
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2020-08-19
Correction Date: 2020-09-11
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: F

Provide and implement an infection prevention and control program.

Survey Date: 2020-08-03
Correction Date: 2020-09-04
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: D

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2019-12-11
Correction Date: 2020-01-20
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2019-12-11
Correction Date: 2020-01-20
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2019-12-11
Correction Date: 2020-01-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Survey Date: 2019-12-11
Correction Date: 2020-01-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Honor each resident's preferences, choices, values and beliefs.

Survey Date: 2019-12-11
Correction Date: 2020-01-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide activities to meet all resident's needs.

Survey Date: 2019-12-11
Correction Date: 2020-01-20
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Survey Date: 2019-12-11
Correction Date: 2020-01-20
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Survey Date: 2019-12-11
Correction Date: 2020-01-20
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2019-12-11
Correction Date: 2020-01-20
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2019-12-11
Correction Date: 2020-01-20
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

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.

Survey Date: 2019-12-11
Correction Date: 2020-01-20
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2018-09-18
Correction Date: 2018-10-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Keep residents' personal and medical records private and confidential.

Survey Date: 2018-09-18
Correction Date: 2018-10-11
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2018-09-18
Correction Date: 2018-10-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2018-09-18
Correction Date: 2018-10-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Assist a resident in gaining access to vision and hearing services.

Survey Date: 2018-09-18
Correction Date: 2018-10-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2018-09-18
Correction Date: 2018-10-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2018-09-18
Correction Date: 2018-10-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Survey Date: 2018-09-18
Correction Date: 2018-10-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide or obtain dental services for each resident.

Survey Date: 2018-09-18
Correction Date: 2018-10-11
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2018-09-18
Correction Date: 2018-10-11
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that residents are fully informed and understand their health status, care and treatments.

Survey Date: 2017-04-20
Correction Date: 2017-06-02
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2017-04-20
Correction Date: 2017-06-27
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Allow residents to self-administer drugs if determined safe.

Survey Date: 2017-04-20
Correction Date: 2017-06-02
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Keep each resident free from physical restraints, unless needed for medical treatment.

Survey Date: 2017-04-20
Correction Date: 2017-06-02
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: E

Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.

Survey Date: 2017-04-20
Correction Date: 2017-06-02
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: N

Scope/Severity: D

Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2017-04-20
Correction Date: 2017-06-27
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2017-04-20
Correction Date: 2017-06-02
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Provide care by qualified persons according to each resident's written plan of care.

Survey Date: 2017-04-20
Correction Date: 2017-07-28
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: G

Give the right treatment and services to residents who display physical or psychosocial problems adapting to changes in circumstances.

Survey Date: 2017-04-20
Correction Date: 2017-06-27
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: G

Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

Survey Date: 2017-04-20
Correction Date: 2017-06-02
Category: Environmental Deficiencies
From Complaint: N

Scope/Severity: E

Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.

Survey Date: 2017-04-20
Correction Date: 2017-06-02
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Store, cook, and serve food in a safe and clean way.

Survey Date: 2017-04-20
Correction Date: 2017-06-02
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Give or get specialized rehabilitative services per the patient's assessment or plan of care.

Survey Date: 2017-04-20
Correction Date: 2017-06-02
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: G

Provide or obtain dental services for each resident.

Survey Date: 2017-04-20
Correction Date: 2017-06-27
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.

Survey Date: 2017-04-20
Correction Date: 2017-06-02
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

Survey Date: 2017-04-20
Correction Date: 2017-06-02
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.

Survey Date: 2017-04-20
Correction Date: 2017-06-02
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: D

Keep accurate, complete and organized clinical records on each resident that meet professional standards.

Survey Date: 2017-04-20
Correction Date: 2017-06-27
Category: Administration Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**