Madonna Gardens

87465 Incidental Medical and Dental Care(4) The licensee shall assist residents with self-administered medications as needed.nThe following requirement has not been met as evidenced by: Facility residents did not get their PM medications on 03/22/2026, and 03/23/2026, which poses an immediate health, safety or personal rights risk to residents in care.

Based on observation, record review the licensee did not comply with the section cited above in Resident 5's medication count is off by 2 doses, Resident 3 was given an extra dose of a medication on 07/16/2025, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in LPA observed water temperature in room 107 measured 123 degrees, which poses/posed a potential health, safety or personal rights risk to persons in care.

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. The following requirements have not been met as evidenced by: Based on interviews conducted, and observation facility residents are being disrupted by doors closing loudly, and staff speaking loudly, which poses a potential, health, safety, or personal rights risk to residents in care.

87465Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: Resident 1's had ongoing symptoms of a skin condition. Resident 1's Physician recommended they be seen by a dermatologist several times

Based on record review, the licensee did not comply with the section cited above in Resident 1 does not have a current hospice plan of care on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

87211(a)Reporting Requirements. Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.(D)Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.The following requirement has not been met as evidenced by: Facility staff did not report Resident 1's fall and transfer to hospital, which poses a potential, health, safety, or personal rights risk to residents in care.

87468.1 Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.The following requirement has not been met as evidenced by: Staff 1 exposed Resident 2's skin in a facility common area in front of other residents, and visitors. which poses

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. The following requirement has not been met as evidenced by: Resident 1 was not provided prescribed medication for more than a month, which poses an immediate, health, safety, or personal rights risk to residents in care.

87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.(D)Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.The following requirement has not been met as evidenced by: The facility did not report Resident 1's missed medications to State Licensing, or Resident 1's Responsible party, which poses a potential, health, safety, or personal rights risk to residents in care.

87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications as needed. The following requirement has not been met as evidenced by: Resident 1 was not given medication on 04/07/2024, and 4/08/2024, which poses an immediate, heatlh, safety, or personal rights risk to residents in care.

87468.1 Personal Rights of Residents in All Facilities.(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1)To be accorded dignity in their personal relationships with staff, residents, and other persons. The following requirement has not been met as evidenced by: Resident 1 has been in several alteractions with other facility residents which poses an immediate, health, safety, or personal rights risk to residents in care.

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. The following requirement has not been met as evidenced by: The facility did not document Responsible parties for several residents being notified after physical altercations Resident 1.

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(1) The facility has a nonambulatory fire clearance for each room that will be used to accommodate a resident with dementia who is unable to or unlikely to respond either physically or mentally to oral instructions relating to fire or other dangers and to independently take appropriate actions during emergencies or drills. The following requirement has not been met as evidenced by: LPA Hurt observed all Memory Care facility doors to be locked preventing emergency personnel services from easily entering rooms which poses an immediate health, safety, or personal rights risk to residents in care.

(a)In each facility: (2) Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice.This requirement is not met as evidenced by: Based on interview and record review, staff did not provide care and supervision when R1 left the facility unsupervised on 04/26/22 at 10:40 a.m. and was located at 10:45 a.m. by facility neighbor which poses an immediate health and safety risks to persons in care.

Incidental Medical and Dental Care A plan for incidental medical and dental care shall be developed...The licensee shall assist residents with self administered medications as needed. This regulation was not met as evidence by: The licensee did not provide R1 with required refrigerated medication timely. Based on records reviewed, R1 was given four medication which were the wrong medication on 9/17/2021. This poses an immediate risk to residents in care.

87411 Personnel Requirements(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (4) Knowledge required to safely assist with prescribed medications which are self administered. This requirement was not met as evidenced by records reviewed Medtech 1 was not properly trained prior to administering medication. This is an immediate heath and safety risk to residents in care.