Madonna Manor
Madonna Manor in Villa Hills, KY — inspection on January 3, 2025.
Found 5 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
F-F580.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
185241
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 185241 B.
Wing 01/03/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Madonna Manor 2344 Amsterdam Road Villa Hills, KY 41017
F-F655.
2.
Additionally, the facility admitted R2 on 10/09/2024 and assessed the resident to be at risk for developing pressure injuries. On 10/18/2024 an unstageable wound to R2's left heel was identified by the Physical Therapy staff, with nursing staff notified by them. R2's baseline care plan, still in effect, did not address or revise for R2's existing skin issues or breakdown.
Refer to
Review of R3's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 12/01/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 14 out of 15, which indicated R3 was cognitively intact.
Review of R3's Physician Orders, located in the resident's electronic medical record (EMR), revealed on 11/26/2024, R3 was ordered cefepime, 2 grams (gm) IV twice daily at 9:00 AM and 9:00 PM for the treatment of infections.
Additionally, on the same date, R3 was prescribed metronidazole, 500 milligrams (mg) one oral tablet taken every eight hours for infections.
Review of R3's MAR, dated 11/2024, and located in the resident's EMR, revealed the facility failed to administer three doses of ordered cefepime on 11/26/2024 at 9:00 PM; 11/27/2024 at 9:00 AM; and on 11/29/2024 at 9:00 AM.
Further review revealed nursing staff administered IV antibiotics to R3 outside the scheduled parameters according to facility policy on four occasions: 1) on 11/27/2024 the 9:00 PM dose was administered on 11/28/2024 at 12:06 AM, resulting in a delay of two hours and six minutes; 2) on 11/29/2024 the 9:00 PM dose was administered at 10:30 PM, resulting in a delay of 30 minutes; 3) on 11/30/2024 the 9:00 AM dose was administered at 12:36 PM, resulting in a delay of two hours and 36 minutes; and 4) on 11/30/2024 the 9:00 PM dose was administered to R3 at 12:04 AM on 12/01/2024, resulting in a delay of two hours and four minutes.
Review of R3's MAR, dated 12/2024, revealed the facility failed to administer one dose of ordered cefepime on 12/01/2024 at 9:00 AM.
Review of R3's MAR, dated 11/2024, revealed the facility failed to administer the following four doses of metronidazole: 11/26/2024 at 10:00 PM; 11/27/2024 at 6:00 AM or 2:00 PM; and 11/28/2024 at 2:00 PM.
Review of R3's MAR, dated 12/2024, revealed the facility failed to administer one dose of metronidazole on 12/01/2024 at 6:00 AM.
Review of R3's Nurse's Note, dated 12/01/2024 at 11:52 AM and authored by LPN1, revealed R3 was transferred to the local ED. LPN1 stated R3's family alerted staff that R3 was not responding. LPN1 stated upon assessment, R3 was lethargic, difficult to arouse, and would only respond to painful stimuli.
She noted bodily tremors were observed.
185241
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 185241 B.
Wing 01/03/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Madonna Manor 2344 Amsterdam Road Villa Hills, KY 41017
Review of R3's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 12/01/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 14 out of 15, which indicated R3 was cognitively intact.
Continued review revealed R3 was assessed as being independent with activities of daily living (ADL), and R3 ambulated per self via wheelchair and walker.
Review of R3's Nurse's Note, dated 12/01/2024 at 11:52 AM and authored by LPN1, revealed R3 was transferred to the local ED. LPN1 stated R3's family alerted staff that R3 was not responding. LPN1 stated upon assessment, R3 was lethargic, difficult to arouse, and would only respond to painful stimuli.
She noted bodily tremors were observed.
Review of R3's ED Provider Notes, dated 12/01/2024, revealed R3 presented to the ED in an altered mental status, septic, and in atrial fibrillation with rapid ventricular response (AFib RVR). R3 was febrile.
His mental status was noted as somnolent, opened eyes to verbal stimuli, but was not conversant.
Further review of the note revealed the physician stated, Upon my evaluation the patient had a high probability of imminent or life-threatening deterioration due to presentation which required my direct attention, intervention, and immediate management.
During an interview with Family Member (F) 2 on 12/18/2024 at 12:23 PM, she stated when family came to visit R3 on 12/01/2024 at 11:10 AM, they found R3 unresponsive, feverish, sweaty, and exhibiting seizure like activity. F2 stated the family alerted LPN1 of R3's CIC, and they requested LPN1 to call emergency medical services (EMS) for transfer to the local emergency department. F2 stated R3 was admitted to the local hospital's critical care unit (CCU) for several weeks.
She stated R3 had returned home and required an additional 10 weeks of intravenous [IV] antibiotic therapy.
Additionally, F2 stated LPN1 admitted she was made aware of R3's CIC at 7:00 AM, during the shift change report. F2 stated LPN1 told her LPN1 had not seen R3 or assessed him that morning.
185241
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 185241 B.
Wing 01/03/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Madonna Manor 2344 Amsterdam Road Villa Hills, KY 41017
F-F760 also constituted Substandard Quality of Care (SQC) at 42 CFR 483. 45.
The facility was notified of the IJ on 12/20/2024 at 1:15 PM.
On 12/20/2024 at 1:15 PM, the facility's Executive Director, Unit Manager, and Infection Preventionist were provided a copy of the IJ Template and notified that the facility failed to have a system to ensure R3's medications were administered as ordered and verified.
This failure is likely to cause serious injury, impairment, or death.
The facility provided an acceptable IJ Removal Plan, on 01/02/2025 at 1:45 PM, alleging removal of the IJ on 01/02/2025.
The State Survey Agency (SSA) validated the IJ had been removed on 01/02/2025 at 1:45 PM, after an acceptable Removal Plan was received and further interviews, observations, and record reviews were conducted to verify the immediate corrections.
Remaining non-compliance continued at a S/S of a D (no actual harm with a potential for more than minimal harm that is not immediate jeopardy) at