Madonna Manor

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 34 185241 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 2. In addition, on 10/18/2024, an unstageable wound to Resident R2's left heel was found by the physical therapy (PT) staff. The nursing staff was notified. However, the nursing staff failed to notify the physician of a change in Level of Harm - Immediate condition (CIC) immediately. A review of a progress note dated 10/23/2024 by the Wound Care Physician jeopardy to resident health or revealed the provider noted a newly acquired unstageable deep tissue injury (DTI) measuring (length (L) x safety width (W) x depth (D)): 5.0 x 8.0 x 0.1 centimeter (cm) with etiology (cause) noted from pressure.

Residents Affected - Few Refer to

F-F655.

2. Additionally, the facility admitted Resident 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 Resident R2's left heel was identified by the Physical Therapy staff, with nursing staff notified by them. Resident R2's baseline care plan, still in effect, did not address or revise for Resident R2's existing skin issues or breakdown.

Refer to

F-F684

The findings include:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 34 185241 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Review of the facility's policy titled, Medication Administration, undated, revealed medications were administered as prescribed by the physician and in accordance with established professional standards of Level of Harm - Immediate practice. Further review revealed the facility upheld the rights related to medication administration, which jeopardy to resident health or included ensuring medications were given at the appropriate times. Per the policy, all medications should be safety administered within 60 minutes prior to or after the scheduled time.

Residents Affected - Few Closed Record Review of Resident R3's Face Sheet, located in the resident's electronic medical record (EMR), revealed the facility admitted the resident on 11/26/2024 with diagnoses to include post laminectomy syndrome, post-surgical infection of the intrathecal pain pump, and idiopathic peripheral neuropathy.

Review of Resident 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 Resident R3 was cognitively intact.

Review of Resident R3's Physician Orders, located in the resident's electronic medical record (EMR), revealed on 11/26/2024, Resident 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, Resident R3 was prescribed metronidazole, 500 milligrams (mg) one oral tablet taken every eight hours for infections.

Review of Resident 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 Resident 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 Resident R3 at 12:04 AM on 12/01/2024, resulting in a delay of two hours and four minutes.

Review of Resident 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 Resident 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 Resident 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 Resident R3's Nurse's Note, dated 12/01/2024 at 11:52 AM and authored by LPN1, revealed Resident R3 was transferred to the local ED. LPN1 stated Resident R3's family alerted staff that Resident R3 was not responding. LPN1 stated upon assessment, Resident R3 was lethargic, difficult to arouse, and would only respond to painful stimuli. She noted bodily tremors were observed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 34 185241 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Review of Resident R3's ED Provider Notes, dated 12/01/2024, revealed Resident R3 presented to the ED in an altered mental status, septic, and in atrial fibrillation with rapid ventricular response (AFib RVR). Resident R3 was febrile. His mental Level of Harm - Immediate status was noted as somnolent, opened eyes to verbal stimuli, but was not conversant. Further review of the jeopardy to resident health or note revealed the physician stated, Upon my evaluation the patient [resident] had a high probability of safety imminent or life-threatening deterioration due to presentation which required my direct attention, intervention, and immediate management. Residents Affected - Few

During an interview with Family Member (F) 2 on 12/18/2024 at 12:23 PM, she stated when family came to visit Resident R3 on 12/01/2024 at 11:10 AM, they found Resident R3 unresponsive, feverish, sweaty, and exhibiting seizure like activity. F2 stated the family alerted LPN1 of Resident R3's change in condition (CIC), and they requested LPN1 to call emergency medical services (EMS) for transfer to the local emergency department. F2 stated Resident R3 was admitted to the local hospital's critical care unit (CCU) for several weeks. She stated Resident R3 had returned home and required an additional 10 weeks of intravenous [IV] antibiotic therapy.

During an interview with LPN1 on 12/18/2024 at 11:58 AM, she stated at the time the family made her aware of Resident R3's CIC at around 11:00 AM, she had not seen Resident R3 and had not given him his 9:00 AM dose of IV antibiotics. LPN1 stated that all medications should be given as ordered. During further interview, LPN1 stated that on 12/01/2024, it was a particularly busy day, and she had fallen behind on her assessments and medication administration. She stated she had tried her best to manage her tasks. Additionally, LPN1 stated

she did not recall if she communicated her need for assistance or asked the unit coordinator (UC) for support.

During an interview with the Advanced Practice Registered Nurse (APRN) on 12/20/2024 at 1:15 PM, she stated she expected the nursing staff to administer medication as ordered by the medical provider. She stated administering medication on time, every time, was important to ensure that all bacteria causing the infection were eliminated. She stated this was also the best approach to prevent the infection from recurring.

During a telephone interview with the Medical Director on 12/19/2024 at 12:40 PM, he stated he expected

the nursing staff to administer medication as ordered by the medical provider. The Medical Director stated administering antibiotics on time was important to ensure that all bacteria causing the infection were eliminated and to prevent the infection from recurring. Per the interview, the Medical Director stated it was his expectation that staff followed all facility policies to ensure quality of care and the safety of the residents.

During an interview with Registered Nurse (RN) 4/Unit Manager (RN/UM) on 12/18/2024 at 12:51 PM, she stated nursing staff should administer antibiotic medication as ordered to treat and prevent the infection from recurring. She stated that administering medication timely was important for the resident's safety and well-being.

During an interview with the Interim Director of Nursing (IDON) on 12/18/2024 at 10:06 AM, she stated the unit managers were responsible for auditing medication administration on their units; however, there was no formal documentation of those audits. The IDON stated it was her expectation that licensed staff should administer antibiotics as prescribed and timely to ensure the infection was treated and to prevent recurrence.

She further stated that timely medication administration was crucial for the resident's safety and well-being.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 34 185241 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 During an interview with the Executive Director (ED) on 12/19/2024 at 1:08 PM, she stated it was her expectation that staff adhered to the facility's medication administration policy. The ED stated following the Level of Harm - Immediate medical provider's orders was crucial for ensuring safe and appropriate care for all residents. jeopardy to resident health or safety The facility provided an acceptable removal action plan on 01/02/2025 at 1:45 PM that read verbatim:

Residents Affected - Few Resident #3 was discharged from [Facility Name] on 12/1/24.

Identification of Residents Affected or Likely to be affected:

Residents currently at [Facility Name].

Actions to prevent occurrence/recurrence:

l. An Ad Hoc QAPI meeting was held with DON, Medical Director and ED on 12/20/24 discussed IJ

regarding Medication Administration for Medical Director input.

2. The Corporate Clinical team, VP of Operations, Executive Director and DON discussed the Medication Administration policy and the plan for abatement. 12/20/24

3. The Director of Clinical Risk Management reviewed the Medication Administration policy. Completed 12/20/24.

4. The Director of Clinical Risk Management educated the DON and Nurse Managers regarding the Medication Administration policy. Completed 12/20/24

5. 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. Completed 12/20/24

6. 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.

7. 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 on [DATE REDACTED]th and [DATE REDACTED]th at the Monthly All Staff Clinical Meeting. Beginning 12/21 the DON/Nurse Managers started referencing the Nurse Clinical Binder as education on step by step guides for nurses and KMAs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 34 185241 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 8. 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 Level of Harm - Immediate weekly. jeopardy to resident health or safety 9. Starting 12/21/24, DON/Nurse Manager completes audit daily 7 days per week using Medication Admin Audit Report in PCC. DON/ Nurse Managers address issues immediately with appropriate nurse or KMA and Residents Affected - Few assures follow up regarding notification policy.

10. Starting on 12/21 Nurse Managers provided daily 1:1 Nurse/KMA coaching to ensure medication administration per MD orders.

11. Starting with admissions on or after 1/1/25 DON/Nurse Managers compare the hospital discharge summary to the MD orders in PCC for all new admissions, within 12 hours of admission, to assure accuracy and timeliness of medication administration. Results of the audits will be reported to the QAPI committee weekly for 4 weeks and every other week until substantial compliance is achieved.

12. DON/Nurse Manager reported results of audits, follow up, and trends to QAPI committee on 12/27/24 and will continue to report data to QAPI weekly for 4 weeks and then every other week until we are in substantial compliance.

13. QAPI meeting on 12/27/24 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.

14. The next QAPI meeting is scheduled for 1/3/25.

Date facility alleges IJ removal: 1/2/2025

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 34 185241 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 44001 Residents Affected - Few Based on interview, record review, and facility policy review, the facility failed to ensure drugs and biologicals were stored according to professional standards for 1 of 3 medication carts where an opened pharmacy delivery tote with medications was left unattended.

The findings include:

Review of the facility's policy titled, Storage of Medications, undated, revealed drugs and biologicals stored in

the facility were kept in locked compartments, accessible only to authorized personnel. According to the policy, nursing staff was responsible for managing medication storage. Per the policy, compartments containing drugs and biologicals must be locked when not in use, and any unlocked medications should not be left unattended.

Observation of a medication cart in the Household B Hall on 12/12/2024 at 10:31 AM, revealed an opened pharmacy delivery tote full of medications. The delivery tote was left opened, unsecured, and unattended out

in the open as residents and staff walked by. The tote contained two boxes of multiple single dose albuterol (bronchodilator) inhalation solution packets for nebulizer treatments, several intravenous (IV) fluid bags containing normal saline, multiple heparin (an anticoagulant) flush injections, and two 100-milliliter (mL) bags of IV ceftriaxone (an antibiotic).

During interview with Licensed Practical Nurse (LPN) 1 on 12/12/2024 at 10:38 AM, she stated the pharmacy had just delivered the medication, and she had not had a chance yet to place the storage tote in the medication storage room. She stated she had stepped away from the cart to administer medication to a resident and was going to place the contents of the tote in the medication cart. LPN1 stated facility protocol was to place medication in the medication storage room or in the designated medication cart when inventory was received from the pharmacy.

During interview with Registered Nurse (RN) 3 on 12/12/2024 at 10:45 AM, she stated medication inventory should be stored in the medication room when it was received from the pharmacy and should never be left unlocked and unattended. She stated leaving medication out could pose a risk to residents.

During interview with the Interim Director of Nursing (IDON) on 12/12/2024 at 10:32 AM, she stated when inventory was received from the pharmacy, it should be put away in its correct location, either in the medication room or in the medication cart. She stated not ensuring medication was stored properly and locked when unattended could pose a safety risk to residents. She stated nursing staff was responsible for

the medication cart, and medication should not be left unattended. The IDON further stated storing medications appropriately prevented the diversion of drugs by other staff members or visitors.

During interview with the Executive Director on 12/19/2024 at 1:08 PM, she stated it was her expectation that staff followed the facility's policy. She stated it was her expectation that staff properly stored and locked medication when it arrived from the pharmacy. She further stated it was important to ensure safe and appropriate care for all residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 34 185241 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44001 potential for actual harm Based on observation, interview, record review, review of the Centers for Disease Control and Prevention Residents Affected - Some (CDC) guidelines, review of the manufacturer's instructions for use, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 11 sampled residents, Residents (R) 4 and Resident R8.

1. Observation on 12/12/2024 of Resident R4's room revealed the resident was under contact isolation precautions. However, staff was observed in the room without wearing the appropriate personal protective equipment (PPE). Further observation on 12/12/2024 revealed another staff member entered Resident R4's room and did not don (put on) PPE.

2. Observation and interview on 12/12/2024 with Licensed Practical Nurse (LPN) 1 revealed she carried a contaminated glucometer (blood sugar measuring device), without wearing gloves, across the common area and placed it on the medication cart without first placing a barrier down. Further observation on 12/18/2024 revealed LPN1 failed to clean the glucometer according to the Environmental Protection Agency (EPA) registered disinfectant manufacturer's instructions.

The findings include:

Review of the CDC's Guidelines, provided by the facility, titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 09/10/2021, revealed reusable medical equipment should be cleaned and disinfected according to manufacturer's instructions or the facility's policies before and after use. The guidelines stated facilities should maintain separation between clean and soiled equipment to prevent cross-contamination. Further

review of the guidelines revealed staff should be trained in the correct steps for cleaning and disinfection of shared equipment.

Review of the facility's policy titled, Infection Prevention and Control Program [IPCP], dated 10/24/2022, revealed the facility maintained an infection prevention and control program designed to provide a safe sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections per accepted national standards and guidelines. Continued review revealed all staff was responsible for following policies and procedures related to the IPCP program to include transmission based precautions. Furthermore, the policy stated all staff should use personal protective equipment (PPE) according to established facility policy governing the use of PPE.

Review of the facility's policy titled, Cleaning and Disinfection of Resident Care Equipment, dated 03/01/2023, revealed shared reusable equipment could be a source of indirect transmission of pathogens.

The policy stated resident care equipment would be cleaned and disinfected in accordance with current CDC recommendations in order to break the chain of infection, and staff would clean and disinfectant in accordance with manufacturers' recommendations. Furthermore, per the policy, staff would clean and disinfect reusable equipment after each use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 34 185241 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Review of the cleaning and disinfecting instructions for the Assure Prism Multi-Blood Glucose Monitoring System, no date, revealed to minimize the risk of transmitting bloodborne pathogens, the exterior of the Level of Harm - Minimal harm or glucometer should be cleaned of all dirt, blood, and bodily fluids before performing the disinfection potential for actual harm procedure, which would prevent the transmission of bloodborne pathogens. Per the instructions, the exterior of the glucometer should remain wet for the appropriate dwell time (time a surface must remain visibly wet Residents Affected - Some after the application of a disinfectant) according to the disinfectant's instructions.

Review of the cleaning and disinfecting instructions for Medline's MicroKill One (blue lid) container revealed for cleaning to use one or more wipes as necessary to wet surfaces sufficiently and to thoroughly clean the surface. Then, the instructions stated to use a second wipe as necessary to thoroughly wet all surfaces to be treated. According to the instructions, all surfaces must remain visibly wet for a one minute dwell time to assure complete disinfection of all pathogens.

1. Review of Resident R4's Face Sheet, located in the resident's electronic health record (EHR), revealed the facility admitted the resident on 12/11/2024 with diagnoses to include pyogenic arthritis right knee, cellulitis of right lower limb, Sjogren syndrome (disorder of the immune system), and history of multidrug-resistant organisms (MDRO).

Review of Resident R4's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 12/12/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, which indicated Resident R4 was cognitively intact.

Review of Resident R4's Discharge Summary, from the resident's previous facility, dated 12/11/2024, located in the resident's EHR, revealed the resident had an infection of the right knee which was positive for staph pseudointermedius and streptococcus mitis, and there was an order for contact isolation precautions.

Observation on 12/12/2024 at 10:33 AM of Resident R4's room, a contact isolation room, revealed the Advanced Practice Registered Nurse (APRN) was in the room sitting on the resident's unmade bed while she talked with the resident. The APRN did not wear a gown or gloves during her time in Resident R4's room.

During interview with the APRN on 12/12/2024 at 10:33 AM, she stated she had entered the room to check

on the resident. She stated it was the facility's policy to wear a gown and gloves at all times while in a contact precaution room to protect both the resident and staff from the spread of infection. She further stated

it was not appropriate to sit on the bed, and sitting on a resident's bed could facilitate the spread of infection.

The APRN stated she had completed multiple education modules related to IPCP training.

Continued observation on 12/12/2024 at 10:35 AM, revealed Registered Nurse (RN) 3 was standing inside Resident R4's room at the end of the bed without wearing a gown and gloves.

During interview with RN3 on 12/12/2024 at 10:50 AM, she stated she was in Resident R4's room just to say hello and did not don (put on) PPE because she was not providing care. When asked by the State Survey Agency (SSA) Surveyor what was required before entering a contact precaution isolation room, RN3 stated gloves and a gown must be worn. She stated transmission-based precautions were important to prevent the spread of infection to other staff and residents. RN3 stated she had received IPCP education upon hire and had multiple in-services related to infection control.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 34 185241 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 2. Review of Resident R8's Face Sheet, located in the resident's EHR, revealed the facility admitted the resident on 11/28/2024 with diagnoses to include left hemiplegia and hemiparesis following cerebral infarction (stroke), Level of Harm - Minimal harm or type 2 diabetes mellitus, and chronic obstructive pulmonary disease (COPD). potential for actual harm

Review of Resident R8's admission MDS, with an ARD of 12/02/2024, revealed the facility assessed the resident to Residents Affected - Some have a BIMS score of 15 out of 15, which indicated Resident R8 was cognitively intact.

Observation on 12/12/2024 at 10:35 AM revealed LPN1, without wearing gloves, brought a glucometer out of Resident R8's room, walked across the common area to the medication cart sitting outside of room [ROOM NUMBER], and then placed the glucometer on the medication cart without using a barrier.

During interview with LPN 1 on 12/12/2024 at 10:38 AM, she stated she had just performed a blood glucose fingerstick on Resident R8 and was coming back to the cart to clean and disinfect the glucometer (because it was contaminated after Resident R8's blood glucose fingerstick). When asked what the process for cleaning the glucometer after use on a resident, she stated it should be cleaned immediately with disinfectant wipes. She further stated she knew not to put it down on the cart without a barrier but added she was nervous due to the SSA Surveyor's presence. LPN1 stated she had received IPCP education upon hire and had also received education through in-service trainings provided by the Infection Preventionist/Wound Care Nurse (IP/WCN) and the Interim Director of Nursing (IDON) related to infection control.

Observation on 12/18/2024 at 12:47 PM revealed LPN1 performed a blood glucose fingerstick on Resident R8. The LPN took the glucometer to the medication cart and placed it on top of the cart without first placing a protective barrier down. LPN1 took a disinfectant wipe out of the MicroKill One Wipes container and wiped

the glucometer for 10 seconds. She then placed the glucometer in the top drawer of the medication cart.

During additional interview with LPN1 on 12/18/2024 at 12:47 PM, she stated she was educated to place the glucometer on a barrier and clean and disinfect it with the MicroKill One Wipes. When asked what the dwell time for the wipes was, she stated, One minute. When asked to discuss the facility's protocol for cleaning and disinfecting the shared glucometer, LPN1 could not articulate what the kill time meant and was unable to correctly list the steps for cleaning the glucometer.

During interview with the IP/WCN on 12/17/2024 at 11:15 AM, she stated the facility followed CDC guidelines and recommendations related to IPCP. She stated she provided education to all staff related to IPCP, and all staff was trained on the use of PPE and isolation precautions to include contact precautions. She stated gowns and gloves must be worn whenever staff entered a contact precaution room. Per the interview, the IP/WCN stated she and other nurse leaders had not observed any concerns related to staff's failure to follow infection control or transmission-based precautions protocols. She stated it was her expectation that all staff followed infection prevention control practices. The IP/WCN stated it was important for the safety of residents and staff and to prevent the spread of infection. She also stated nursing staff was trained to clean and disinfect the glucometer after each use using the blue topped MicroKill One Wipes cleaning and disinfectant wipes with a one minute dwell time. She stated contaminated glucometers should be placed on a barrier cloth to prevent the spread of infection and cleaned, then disinfected for the appropriate time and stored separately to keep clean.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 34 185241 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During interview with the IDON on 12/18/2024 at 1:19 PM, she stated all staff received IPCP training upon hire and periodically throughout the year. In addition, the IDON stated staff was updated on current CDC Level of Harm - Minimal harm or guidelines when they changed. She stated nursing leadership audited staff for compliance. However, she potential for actual harm stated there was no documentation of staff IPCP audits. Per interview, it was the IDON's expectation that all staff maintained IPCP guidelines at all times to decrease the potential spread of infection. Residents Affected - Some

During interview with the Executive Director on 12/19/2024 at 1:08 PM, she stated it was her expectation that staff followed the facility's IPCP policies and procedures to prevent the spread of infection to residents and staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 34 185241

F-F686

The findings include:

Review of the facility's policy titled, Notification of Change of Condition, undated, revealed the facility would consult with the resident's medical provider when there was a significant change in the resident's physical health.

1. Closed Record Review of Resident R3's Face Sheet, located in the resident's electronic medical record (EMR), revealed the facility admitted the resident on 11/26/2024 with diagnoses to include post laminectomy syndrome (chronic pain following back surgery; a laminectomy was removing part or all of the bony arch that covered the spinal cord); post-surgical infection of the intrathecal (the space between the spinal cord and the membranes that protect it) pain pump, and idiopathic peripheral neuropathy.

Review of Resident 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 Resident R3 was cognitively intact. Continued review revealed Resident R3 was assessed as being independent with activities of daily living (ADL), and Resident R3 ambulated per self via wheelchair and walker.

Review of Resident R3's Nurse's Note, dated 12/01/2024 at 11:52 AM and authored by LPN1, revealed Resident R3 was transferred to the local ED. LPN1 stated Resident R3's family alerted staff that Resident R3 was not responding. LPN1 stated upon assessment, Resident R3 was lethargic, difficult to arouse, and would only respond to painful stimuli. She noted bodily tremors were observed.

Review of Resident R3's ED Provider Notes, dated 12/01/2024, revealed Resident R3 presented to the ED in an altered mental status, septic, and in atrial fibrillation with rapid ventricular response (AFib RVR). Resident 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 Resident R3 on 12/01/2024 at 11:10 AM, they found Resident R3 unresponsive, feverish, sweaty, and exhibiting seizure like activity. F2 stated the family alerted LPN1 of Resident R3's CIC, and they requested LPN1 to call emergency medical services (EMS) for transfer to the local emergency department. F2 stated Resident R3 was admitted to the local hospital's critical care unit (CCU) for several weeks. She stated Resident 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 Resident R3's CIC at 7:00 AM, during the shift change report. F2 stated LPN1 told her LPN1 had not seen Resident R3 or assessed him that morning.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 34 185241 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 During an interview with LPN1 on 12/18/2024 at 11:58 AM, she stated she received in report from RN2 that Resident R3 was lethargic and had an altered mental status overnight, but RN2 reported to her that Resident R3 was fine after Level of Harm - Immediate aides changed him. She further stated she did not assess Resident R3's condition at the beginning of her shift. jeopardy to resident health or Furthermore, LPN1 stated she did not chart or notify the physician of the resident's CIC. LPN1 stated at the safety time the family made her aware of his CIC at around 11:00 AM, she had not seen Resident R3 and had not given him his 9:00 AM dose of IV antibiotics. Residents Affected - Few

During an interview with the Advanced Practice Registered Nurse (APRN) on 12/20/2024 at 1:15 PM, she stated she expected the nursing staff to notify the provider of any changes in the resident's mental or physical condition. The APRN stated nursing staff should notify the provider immediately when a resident's mental status changed. She further stated that making the provider aware of a CIC was necessary for the resident's safety and well-being.

During a telephone interview with the Medical Director on 12/19/2024 at 12:40 PM, he stated the nurse on duty should have communicated changes in the resident's condition immediately to the providers. He stated nurses were to use their nursing judgment and notify the provider on-call in emergency situations. Per the interview, the Medical Director stated it was his expectation that staff followed all facility policies to ensure

the safety of the residents.

2. Closed Record Review of Resident R2's Face Sheet, located in the resident's EMR, revealed the facility admitted

the resident on 10/09/2024 with diagnoses to include idiopathic hydrocephalus, peripheral vascular disease, and chronic total occlusion of artery of the extremities.

Review of Resident R2's admission MDS, with an ARD of 10/14/2024, revealed the facility assessed the resident to have a BIMS score of nine out of 15, which indicated Resident R2 was moderately cognitively impaired. Continued

review revealed Resident R2 was assessed as being dependent (helper did all the effort) with mobility, toileting, and transfers. Resident R2 was assessed as needing substantial/maximal assist (helper did more than half the effort) with positioning in bed.

Review of Resident R2's Physical Therapy Treatment Encounter Note, dated 10/18/2024 at 5:11 PM, revealed the Physical Therapist (PT) noted an unstageable wound to Resident R2's left heel. According to the note, PT notified nursing staff and educated them to float Resident R2's heels when in bed.

Review of Resident R2's EMR revealed there was no documentation by nursing on 10/18/2024 related to the wound found by PT. Additionally, there was no documentation indicating the facility notified the physician about Resident R2's change in

physical condition.

Review of Resident R2's Occupational Therapy (OT) Treatment Encounter Note, dated 10/19/2024 at 11:16 AM, revealed Resident R2 attempted activities of daily living (ADL) tasks but could not continue due to a wound that caused a barrier to OT treatment. The note stated the resident is struggling to move the left leg.

Review of Resident R2's EMR revealed there was no documentation by nursing on 10/19/2024 related to the wound found by PT. Additionally, there was no documentation indicating the facility notified the physician about Resident R2's change in

physical condition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 34 185241 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Review of Resident R2's Occupational Therapy (OT) Treatment Encounter Note, dated 10/21/2024 at 4:01 PM, revealed the resident had a new wound on her left lower extremity and nursing instructed OT not to stand Level of Harm - Immediate [Resident R2] this date. jeopardy to resident health or safety Review of Resident R2's EMR revealed no documentation regarding the wound's worsening condition or an order for non-weight bearing status by nursing on 10/21/2024. Residents Affected - Few

Review of Resident R2's Physical Therapy Treatment Encounter Note, dated 10/21/2024 at 4:58 PM, revealed the PT noted, after attempting gait training, that nursing entered the therapy gym and examined Resident R2's left heel ulcer. According to PT, the ulcer appeared to have grown in size since 10/18/2024 and was secreting bloody drainage. Nursing instructed PT to hold gait training.

Review of Resident R2's EMR revealed no documentation regarding the wound's worsening condition by nursing on 10/21/2024. Additionally, there was no documented evidence nursing staff informed the physician about Resident R2's change in physical condition.

Review of Resident R2's EMR revealed new orders were given by the Advanced Practice Nurse Practitioner (APRN)

on 10/21/2024 at 11:39 AM, for bilateral pressure boots and new skin treatment orders.

Review of Wound Evaluation and Management Summary, dated 10/23/2024, revealed the wound specialty physician noted Resident R2 to have developed an unstageable deep tissue injury to her left heel measuring (L x W x D): 5.0 x

8.0 x 0.1 cm, with etiology noted from pressure. New treatment and medication orders were given.

During an interview with F1 on 12/16/2024 at 9:26 AM, she stated Resident R2 was currently receiving treatment at another facility for an unstageable pressure ulcer (PU) on her left heel, which she developed while at the facility. F1 expressed concern that the former Director of Nursing (DON) did not listen to the family's concerns or notify the medical provider when physical therapy discovered the pressure ulcer.

During an interview with the PT Manager on 12/17/2024 at 10:55 AM, she stated she observed a change in Resident R2's heel on 10/18/2024. The PT Manager stated the wound was closed and had a slight discoloration to the skin, but the area was red and blanchable. She stated she collaborated with the nursing staff to offload pressure and apply boots to both feet. According to the PT Manager, the wound status changed significantly from Friday (the 18th) to Monday (the 21st). She stated, on 10/21/2024, the area on Resident R2's left heel was an open blister, and she could not complete her therapy session due to pain in Resident R2's left foot. She stated she requested nursing staff to assess Resident R2's left heel wound. She stated, upon assessment, the wound had grown

in size and was secreting blood and drainage.

During an interview with the Infection Preventionist/Wound Care Nurse (IP/WCN) on 12/19/2024 at 10:17 AM, she stated, on 10/22/2024, she completed a skin assessment on Resident R2 and found an open area on the resident's left heel. She stated she notified the Wound Care Physician, who provided new treatment orders.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 34 185241 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 During an interview with the Wound Care Physician on 12/19/2024 at 12:06 PM, she stated on 10/23/2024,

she examined Resident R2's wound and found that the resident had an unstageable deep tissue injury on the left heel Level of Harm - Immediate caused by pressure. She stated she ordered a new treatment regimen and prescribed an oral antibiotic. jeopardy to resident health or Additionally, she stated she instructed the staff to have the resident wear pressure-relieving boots and to safety ensure the wound was offloaded.

Residents Affected - Few During an interview with the former DON on 12/16/2024 at 1:45 PM, she stated Resident R2 had not been at the facility for long, and her daughter had some medical background. She stated Resident R2 developed a wound on her left heel while at the facility and was seen by the wound care team. She stated she could not state who called the physician, but she was confident nursing staff had notified the physician immediately when the wound was discovered. She stated the nurses on duty at the time of the discovery of the wound no longer worked at the facility.

During an interview with the Interim Director of Nursing (IDON) on 12/19/2024 at 9:38 AM, she stated it was her expectation for all nursing staff to follow the facility's policies and procedures regarding a resident's CIC.

She stated nursing staff should notify the physician immediately of any injury, fall, or decline in status as per

the policies and procedures. The IDON stated following procedures related to a resident's CIC ensured the resident received appropriate and timely care.

During an interview with the Executive Director on 12/19/2024 at 1:08 PM, she stated it was her expectation that staff followed the facility's policy to notify the physician to ensure safe and appropriate care for all residents.

The facility provided an acceptable removal action plan on 01/02/2025 at 1:45 PM that read verbatim:

Resident #3 was discharged from [Facility Name] on 12/1/24.

Identification of Residents Affected or Likely to be affected:

All residents currently at [Facility Name].

Actions to prevent occurrence/recurrence:

l. An Ad Hoc QAPI meeting was held with DON, Medical Director and ED on 12/20/24 discussing IJ

regarding Notification of Changes for Medical Director input.

2. Notification of Changes policy was reviewed immediately by the Director of Clinical Risk Management. Completed 12/20/24

3. The Director of Clinical Risk Manager provided education for the Director of Nursing, Executive Director and Nurse Managers regarding the Notification of Changes policy. Completed 12/20/24.

4. The Executive Director, Corporate Clinical Leadership Team, Director of Clinical Risk, DON discussed the Notification of Changes policy and the plan for the abatement. Completed 12/20

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 34 185241 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 5. 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 Level of Harm - Immediate nurse on leave will be educated by DON/Nurse Managers prior to her return to work., 2 staff still to complete jeopardy to resident health or prior to their next shift. safety 6. Starting 12/21/24 all nurses and KMAs who are hired will be educated by the DON/Nurse Managers Residents Affected - Few regarding the Notification of Changes policy prior to working.

7. All progress notes were reviewed from 11/26/24 to current by DON/Nurse Manager for changes in condition of identified residents and proper notification of MD and Responsible Party as appropriate. Completed 12/20/24

8. 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. Completed 12/20/24.

9. Beginning 12/21/24 - The 24 hour report sheet and the 24 hour summary in Point Click Care

{PCC) will be reviewed by DON/Nurse Manager daily 7 times per week for appropriate notification of changes in the morning Clinical Meeting.

10. Starting 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.

11. DON reported audit results regarding notification of changes missed at the 12/27 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.

12. QAPI meeting on 12/27/24 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.

13. Next QAPI meeting scheduled for 1/3/25.

Date facility alleges IJ removal: 1/2/2025

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 34 185241 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0583 Keep residents' personal and medical records private and confidential.

Level of Harm - Minimal harm or 44001 potential for actual harm Based on observation, interview, record review, and facility policy review, the facility failed to ensure the Residents Affected - Few resident's right to privacy was honored for 1 of 11 sampled residents, Resident (R) 8.

On 12/18/2024, Licensed Practical Nurse (LPN) 1 lifted Resident R8's shirt and exposed her abdomen while she administered an insulin injection to the resident. Resident R8 was seated at a dining table with three other residents eating lunch.

The findings include:

Review of the facility's policy titled, Resident Rights, dated 10/24/2022, revealed the resident had a right to be treated with respect and dignity. Further review revealed the resident had a right to personal privacy and confidentiality to include personal privacy for medical treatment.

Review of Resident R8's Face Sheet, located in the resident's electronic medical record (EMR), revealed the facility admitted the resident on 11/28/2024 with diagnoses to include left hemiplegia and hemiparesis following cerebral infarction (stroke), type 2 diabetes mellitus, and chronic obstructive pulmonary disease (COPD).

Review of Resident R8's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 12/02/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 out of 15, which indicated Resident R8 was cognitively intact.

Review of Resident R8's Physician Orders, dated 11/2024, revealed the resident was to be administered insulin lispro subcutaneous solution 200 units/milliliter (u/mL), per sliding scale before meals and at bedtime for type 2 diabetes.

Observation on 12/18/2024 at 12:45 PM of the lunch service in the common area of Household B, LPN1 lifted Resident R8's shirt, which exposed the right side of her abdomen. LPN1 then administered an insulin injection in

the right upper quadrant of Resident R8's abdomen, while Resident R8 was seated at a dining table with three other residents who were also eating lunch.

During interview with Resident R8 on 12/18/2024 at 1:35 PM, she stated when LPN1 asked her about getting her insulin injection, she consented to receive it at the table while she ate lunch. She stated LPN1 was late administering medications. She stated had she not received her insulin injection in the dining area, she would have been required to return to her room for the injection, resulting in her food getting cold. Additionally, Resident R8 stated it was common practice for nursing staff to administer medication during meals or outside of residents' rooms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 34 185241 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0583 During interview with LPN1 on 12/18/2024 at 12:47 PM, she stated she did not provide privacy for Resident R8 while administering the insulin injection. She stated Resident R8 had given her permission to perform the injection at the Level of Harm - Minimal harm or dining table while Resident R8 was having lunch. LPN1 stated she was having a busy day and was behind on giving potential for actual harm medications. When the State Survey Agency (SSA) Surveyor asked LPN1 if she had consulted all the residents about their comfort with watching her administer an injection while they ate, she stated, No. Residents Affected - Few Furthermore, LPN1 stated, according to facility policy, every resident had the right to privacy and dignity. When asked if she ensured privacy during the medication administration for Resident R8, she stated that she did not.

During interview with the interim Director of Nursing (IDON) on 12/18/2024 at 1:19 PM, she stated nursing staff must always adhere to facility policies and protocols concerning resident rights and privacy. She stated even though the resident had given permission, the facility's protocol required medication to be administered privately in the resident's room. The IDON stated it was unacceptable for LPN1 to administer an injection to a resident in public view while the resident and others were eating a meal. She stated it was her expectation that nursing staff would follow the facility policy to ensure the resident's privacy and dignity.

During interview with the Executive Director on 12/19/2024 at 1:08 PM, she stated it was her expectation that staff followed the facility's policy to include the resident's right to dignity and privacy. She stated following facility policies and protocols was important to ensure safe and appropriate care for all residents.

During interview with the Director of Clinical Risk Management on 12/20/2024 at 12:51 PM, he stated the facility adhered to all nursing care standards set by the Centers for Medicare and Medicaid Services (CMS).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 34 185241 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Level of Harm - Immediate jeopardy to resident health or 44001 safety Based on interview, record review, and review of the facility's policy, the facility failed to develop and Residents Affected - Few implement a baseline care plan within 48 hours for each resident that included instructions needed to provide effective and person-centered care of the resident to meet professional standards of quality care for 2 of 11 sampled residents, Resident (R) 2 and Resident R3.

1. On 11/26/2024, the facility admitted Resident R3 with an intrathecal (the space between the spinal cord and the membranes that protect it) pain pump infection, which was being treated with intravenous (IV) antibiotic therapy via a peripherally inserted central catheter (PICC) line. The facility failed to develop a person centered baseline care plan with interventions to address Resident R3's infection, antibiotic therapy, care of the PICC line, or physician notification for worsening condition.

Immediate Jeopardy (IJ) was identified on 12/20/2024 and was determined to exist on 11/26/2024, in the area of 42 CFR S483.21 Baseline Care Plan,

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 Resident 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