🔎 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 Harm | Isolated to Pattern | A - C |
No Actual Harm | Widespread | D - F |
**Actual Harm** | Isolated | G |
**Actual Harm** | Pattern | H |
**Actual Harm** | Widespread | I |
**Immediate Jeopardy** | Isolated | J |
**Immediate Jeopardy** | Pattern | K |
**Immediate Jeopardy** | Widespread | L |
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.
Scope/Severity: D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Scope/Severity: E
Honor the resident's right to organize and participate in resident/family groups in the facility.
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.
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.
Scope/Severity: E
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
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.
Scope/Severity: G
Provide enough food/fluids to maintain a resident's health.
Scope/Severity: D
Provide safe and appropriate respiratory care for a resident when needed.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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.
Scope/Severity: G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Scope/Severity: D
Keep residents' personal and medical records private and confidential.
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.
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.
Scope/Severity: D
Assist a resident in gaining access to vision and hearing services.
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.
Scope/Severity: G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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.
Scope/Severity: D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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.
Scope/Severity: E
Provide and implement an infection prevention and control program.
Scope/Severity: D
Provide and implement an infection prevention and control program.
Scope/Severity: F
Provide and implement an infection prevention and control program.
Scope/Severity: D
Reasonably accommodate the needs and preferences of each resident.
Scope/Severity: D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
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.
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.
Scope/Severity: D
Honor each resident's preferences, choices, values and beliefs.
Scope/Severity: D
Provide activities to meet all resident's needs.
Scope/Severity: D
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Scope/Severity: D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Scope/Severity: D
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Scope/Severity: D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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.
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.
Scope/Severity: D
Keep residents' personal and medical records private and confidential.
Scope/Severity: D
Ensure each resident receives an accurate assessment.
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.
Scope/Severity: D
Assist a resident in gaining access to vision and hearing services.
Scope/Severity: D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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.
Scope/Severity: D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Scope/Severity: D
Provide or obtain dental services for each resident.
Scope/Severity: D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Scope/Severity: D
Ensure that residents are fully informed and understand their health status, care and treatments.
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.
Scope/Severity: D
Allow residents to self-administer drugs if determined safe.
Scope/Severity: D
Keep each resident free from physical restraints, unless needed for medical treatment.
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.
Scope/Severity: D
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity: E
Ensure services provided by the nursing facility meet professional standards of quality.
Scope/Severity: E
Provide care by qualified persons according to each resident's written plan of care.
Scope/Severity: G
Give the right treatment and services to residents who display physical or psychosocial problems adapting to changes in circumstances.
Scope/Severity: G
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
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.
Scope/Severity: D
Store, cook, and serve food in a safe and clean way.
Scope/Severity: D
Give or get specialized rehabilitative services per the patient's assessment or plan of care.
Scope/Severity: G
Provide or obtain dental services for each resident.
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.
Scope/Severity: D
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
Scope/Severity: D
Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.
Scope/Severity: D
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
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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.**