The resident, identified as R3 in federal inspection records, had been admitted to Madonna Manor on November 26, 2024, with an infected pain pump in his spine and was receiving intravenous antibiotic therapy. When family arrived for their visit at 11:10 AM on December 1, they found him unresponsive, feverish, sweaty, and exhibiting seizure-like activity.
LPN1 admitted to investigators she had received reports at 7 AM during shift change that R3 was lethargic and had altered mental status overnight. But she never assessed the resident's condition at the beginning of her shift. She also failed to give him his 9 AM dose of IV antibiotics or notify the physician of his deteriorating state.
"LPN1 told her LPN1 had not seen R3 or assessed him that morning," family member F2 told investigators. The family had to request that LPN1 call emergency medical services for transport to the local emergency department.
Emergency department records revealed R3 arrived septic and in atrial fibrillation with rapid heart rate. The emergency physician documented that R3 had "a high probability of imminent or life-threatening deterioration due to presentation which required my direct attention, intervention, and immediate management."
R3 spent several weeks in the hospital's critical care unit and required an additional 10 weeks of intravenous antibiotic therapy after returning home.
The facility's medical director told investigators nurses should use their judgment and notify providers immediately in emergency situations. The advanced practice nurse stated she expected nursing staff to notify providers immediately when a resident's mental status changed, calling such notification "necessary for the resident's safety and well-being."
A second resident, R2, suffered similar failures in physician notification when therapists discovered a pressure ulcer on her left heel that progressively worsened without medical intervention.
Physical therapist notes from October 18, 2024, documented an unstageable wound to R2's left heel. The therapist notified nursing staff and educated them to float the resident's heels when in bed. But nursing staff never documented the wound discovery or notified the physician.
The wound continued deteriorating over the following days. On October 19, occupational therapy noted R2 could not continue treatment due to the wound causing a barrier to therapy. The resident was struggling to move her left leg. Again, nursing staff failed to document the wound or notify physicians.
By October 21, the wound had grown significantly worse. Physical therapy records show the therapist attempted gait training but nursing staff entered the therapy gym and examined R2's left heel ulcer. The ulcer had grown in size since October 18 and was secreting bloody drainage. Nursing instructed the therapist to stop gait training.
Despite the obvious deterioration, nursing staff still failed to document the worsening condition or inform physicians.
The wound specialty physician who eventually examined R2 on October 23 found an unstageable deep tissue injury measuring 5.0 by 8.0 by 0.1 centimeters caused by pressure. New treatment and medication orders were prescribed.
"The wound status changed significantly from Friday (the 18th) to Monday (the 21st)," the physical therapy manager told investigators. "On 10/21/2024, the area on R2's left heel was an open blister, and she could not complete her therapy session due to pain in R2's left foot."
The infection preventionist who assessed R2 on October 22 confirmed finding an open area on the resident's left heel and notifying the wound care physician for new treatment orders.
Family member F1 expressed concern that the former director of nursing "did not listen to the family's concerns or notify the medical provider when physical therapy discovered the pressure ulcer." R2 was currently receiving treatment at another facility for the pressure ulcer she developed at Madonna Manor.
The former director of nursing told investigators she was "confident nursing staff had notified the physician immediately when the wound was discovered." However, she acknowledged that "the nurses on duty at the time of the discovery of the wound no longer worked at the facility."
Federal inspectors also cited the facility for violating resident privacy rights when LPN1 administered an insulin injection to a cognitively intact resident in full view of other residents during lunch service. The nurse lifted the resident's shirt and exposed her abdomen while she sat at a dining table with three other residents eating lunch.
The resident told investigators she consented to receive the injection at the table because LPN1 was running late with medications and she didn't want her food to get cold. She said it was "common practice for nursing staff to administer medication during meals or outside of residents' rooms."
LPN1 admitted she did not provide privacy for the resident during the injection. When asked if she had consulted all the residents about their comfort watching her administer an injection while they ate, she answered "No."
The interim director of nursing called LPN1's actions "unacceptable" and said facility protocol required medications to be administered privately in residents' rooms, even with resident permission.
Inspectors determined the facility failed to develop proper baseline care plans within 48 hours of admission for both R2 and R3. R3's care plan lacked interventions to address his spinal infection, antibiotic therapy, PICC line care, or physician notification protocols despite his complex medical needs.
The facility submitted a removal action plan on January 2, 2025, including immediate education for all nursing staff on notification policies, daily audits of progress notes, and weekly reporting to the quality assurance committee. Twenty-five of 28 nurses completed the required education, with remaining staff to be trained before their next shifts.
Madonna Manor received immediate jeopardy citations affecting few residents for failures in physician notification and baseline care planning. The privacy violation received a minimal harm citation.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Madonna Manor from 2025-01-03 including all violations, facility responses, and corrective action plans.
