Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Madonna Manor Nursing Home during CMS and state inspections, most recent first.
A facility failed to maintain accurate medical records for a resident requiring assistance with positioning. CNA Positioning Sheets were often left incomplete or blank, with significant documentation gaps over several months. Interviews revealed that CNAs frequently forgot or overlooked documenting due to workload, and the DON was unaware of the issue, highlighting a lack of specific policy for handwritten records.
A resident experienced significant weight loss over six months, but the facility failed to notify the physician as required by policy. Despite documentation of the weight loss in assessments and progress notes, neither the nursing staff nor the RD informed the physician. Interviews confirmed the lack of communication, resulting in a deficiency.
A resident experienced significant weight loss due to the facility's failure to maintain acceptable nutritional status. Despite the resident's expressed food preferences and cognitive awareness, the facility did not implement or document interventions to prevent further weight loss. Staff interviews revealed a lack of awareness and coordination in addressing the resident's dietary needs, and the care plan did not reflect necessary interventions. The physician was not informed of the weight loss, and no medical evaluation was conducted.
The facility failed to document and address concerns raised by the Resident Council, as required by their policy. Despite residents reporting issues such as missing clothing and insufficient housekeeping, these were not reflected in the meeting minutes. The Activity Director controlled the meetings and documentation, and the Administrator was unaware of the lack of review by the Resident Council President.
The facility failed to provide accessible information and forms for filing grievances, preventing residents and families from submitting concerns anonymously. Most residents were unaware of the grievance process, and staff interviews revealed a lack of available forms and procedures. The Administrator admitted the absence of a mechanism for anonymous grievance submission, indicating non-compliance with regulatory requirements.
A resident with dementia and Alzheimer's was placed in a one-piece jumpsuit to prevent feces smearing, but the facility failed to assess if it was the least restrictive option. The facility's policy requires restraint assessments, but no documentation was found. Staff interviews confirmed the jumpsuit was a restraint, but no prior evaluations were conducted.
A resident with a Foley catheter was observed multiple times with the drainage bag exposed and visible to others, compromising their dignity. Despite staff presence, the bag was not covered, and interviews with staff confirmed that the urine should not be visible to maintain dignity.
A resident with an indwelling Foley catheter was found to have their urinary drainage bag resting on the floor without a protective barrier, potentially exposing it to contaminants. Despite staff acknowledging the risk of contamination, the issue was observed on multiple occasions, indicating a failure in maintaining sanitary catheter care.
A resident's CPAP equipment was found in unsanitary conditions, with the machine covered in dust and the mask and tubing left exposed to potential contamination. The resident, who is blind, could not verify if cleaning protocols were followed. Staff interviews confirmed that the equipment was not maintained according to facility procedures.
The facility failed to maintain an effective infection prevention and control program, as evidenced by two incidents involving residents. Staff did not adhere to PPE protocols for Isolation/Droplet Precautions for a resident with COVID-19, and another resident on Enhanced Barrier Precautions was not provided appropriate PPE during high-contact care. These lapses were observed despite clear signage and policy guidelines, indicating a failure to ensure compliance with infection control protocols.
Incomplete Documentation of Resident Positioning
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident who required physical assistance for positioning. The Certified Nurse Aide (CNA) Positioning Sheets, which were supposed to document the resident's positioning every two hours, were often left incomplete or entirely blank. This issue was observed over several months, with significant gaps in documentation for July and August, and a complete absence of records for early September. The facility's policy required CNAs to provide accurate documentation daily on each shift using the Electronic Medical Record (EMR), but the positioning sheets were handwritten and not integrated into the EMR, leading to inconsistencies and omissions. Interviews with CNAs revealed that documentation was supposed to be completed by the end of each shift, but it was often forgotten or overlooked due to the workload and the need to complete other documentation in the computer system. The Director of Nursing (DON) was unaware of the incomplete documentation and acknowledged the lack of a specific policy for handwritten records. The DON expected CNAs to document all care provided every shift, but the positioning sheets were not consistently filled out, and the facility could not locate the resident's positioning sheet for September.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant and ongoing weight loss for a resident, identified as Resident #26, who was admitted in December 2023 with diagnoses including hypothyroidism and dysphagia. The facility's policy required that any significant weight loss be reported to the physician, but this did not occur. The resident experienced a weight loss of 16.8% over six months, which was documented in various assessments and progress notes, yet there was no evidence that the physician was informed. Interviews with staff, including nurses and the registered dietitian (RD), revealed that the resident's weight loss was known, but the responsibility to notify the physician was not fulfilled. The RD noted the weight loss in her assessments but did not notify the physician, believing it was the nursing staff's responsibility. The nursing staff also failed to document any notification to the physician regarding the resident's weight loss. The physician, when interviewed, confirmed that he was not aware of the resident's significant weight loss and had not conducted any further evaluation. The Director of Nurses also reviewed the medical record and found no evidence of physician notification. This lack of communication and failure to follow the facility's policy resulted in the deficiency noted in the report.
Failure to Address Resident's Nutritional Needs and Weight Loss
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident, leading to significant and ongoing weight loss that was unplanned and undesired. The resident, who was admitted with diagnoses including hypothyroidism and dysphagia, experienced a significant weight loss of 16.8% over six months. Despite being cognitively intact and expressing preferences for certain foods, the resident's dietary needs and preferences were not adequately addressed by the facility. The resident reported dissatisfaction with the meals provided and a preference for food brought in by family members, which was not consistently accommodated by the facility. Interviews with staff revealed a lack of awareness and implementation of interventions to prevent further weight loss. The resident's care plan did not reflect any interventions for weight loss prevention, and there was no documentation of efforts to provide preferred foods or meal replacements. The facility's policies on weight loss and meal replacement were not followed, as evidenced by the lack of documentation and communication regarding the resident's weight loss and dietary preferences. The resident's meal intake was inconsistently documented, and there was no evidence of a systematic approach to address the resident's nutritional needs. The facility's failure to address the resident's weight loss and dietary preferences was further compounded by a lack of communication and coordination among staff. The dietitian, food service director, and nursing staff were not aligned in their efforts to provide appropriate interventions, and the resident's care plan did not accurately reflect the resident's nutritional status or needs. The physician was not made aware of the resident's significant weight loss, and no medical evaluation was conducted to determine the cause of the weight loss. This lack of coordination and communication resulted in the resident not receiving the necessary interventions to prevent further weight loss.
Failure to Document and Address Resident Council Concerns
Penalty
Summary
The facility failed to ensure that concerns from the Resident Council were documented and acted upon in a timely manner, as required by their policy. The policy mandates that the facility listens to and follows up on residents' complaints and grievances through Resident Council meetings. However, a review of the Resident Council Meeting Minutes from February 2024 through July 2024 showed no recorded concerns, despite residents reporting issues during a surveyor-led meeting. During a Resident group meeting, several residents expressed that they were discouraged from discussing council matters outside the meetings and that only concerns deemed significant by the Activity Director (AD) were addressed. The residents also reported that the AD directed the meetings and controlled the minutes, which they had never seen. Specific issues such as missing clothing and insufficient housekeeping were mentioned by the residents but were not reflected in the meeting minutes. Interviews with the AD and the Food Service Director (FSD) revealed discrepancies in the documentation and handling of concerns. The AD claimed no concerns had been raised in recent months, while the FSD noted minor issues were discussed but not documented. The Administrator acknowledged that the meeting minutes should reflect all discussions and was unaware of the lack of review by the Resident Council President.
Lack of Accessible Grievance Process for Residents and Families
Penalty
Summary
The facility failed to provide information on how to file a grievance in resident care and public areas, and did not have forms accessible for residents and visitors to anonymously notify the facility of their concerns. The facility's policy on grievances, reviewed in April 2023, outlined that any resident, staff, or family member with a complaint should report it to the charge nurse or social worker, or complete a grievance form. However, during a review of the facility's grievance book for 2024, it was found that only four grievances were completed throughout the year, with three reported by families via email and all forms completed by facility staff for tracking purposes. During a Resident Group Meeting, the majority of residents expressed unawareness of how to file a grievance. Observations during a tour of the facility revealed no evidence of procedures for filing grievances or the availability of grievance forms in public areas. Interviews with various staff members, including nurses, a CNA, the Activity Director, and the Social Worker, indicated a lack of awareness and availability of grievance forms for residents or families to complete on their own. Staff members generally directed residents or families to the Administrator or nursing supervisor if they had a grievance, but there was no process for anonymous grievance submission. The Administrator acknowledged the lack of a mechanism for residents and families to file grievances anonymously and admitted that grievance forms were not available in public areas. The Social Worker confirmed that the facility did not meet regulatory requirements for grievances, as residents and families could not submit grievances anonymously without speaking to a staff member. This deficiency highlights the facility's failure to ensure residents' rights to voice grievances without discrimination or reprisal, as required by regulations.
Failure to Evaluate Restraint Use for Resident
Penalty
Summary
The facility failed to evaluate the use of a one-piece jumpsuit as a restraint for a resident with dementia and late-onset Alzheimer's disease. The resident, who was not cognitively intact, was observed wearing the jumpsuit daily, which was intended to prevent feces smearing behavior. However, the facility did not conduct a restraint assessment to determine if the jumpsuit was the least restrictive option or necessary for managing the resident's behavior. The facility's policy on physical restraints requires that restraints be used only when medically necessary and assessed by an interdisciplinary team. Despite this, there was no documentation of a restraint assessment for the resident, and the care plan lacked information on prior interventions or devices attempted before resorting to the jumpsuit. The CNA care plan card and behavior analysis report indicated the resident's behavior of smearing feces occurred infrequently, and the jumpsuit was introduced to maintain dignity and hygiene. Interviews with facility staff, including a nurse and the Director of Nurses (DON), revealed that the jumpsuit was considered a restraint, but there was no evidence of prior assessments or evaluations to ensure it was the least restrictive option. The DON acknowledged the lack of adherence to guidelines and the need to review the process, indicating a failure in following the facility's systematic process for evaluating and care planning before using restraints.
Failure to Maintain Resident Dignity by Not Covering Foley Catheter Bag
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity by not providing a privacy cover for the resident's Foley catheter drainage bag. The resident, who was admitted in May 2023 and had a diagnosis of urinary tract infection, was observed multiple times with the Foley catheter drainage bag exposed and visible to others. The resident had moderate cognitive impairment and was dependent on staff for personal hygiene and bathing, as indicated by the Minimum Data Set assessment. On several occasions, the surveyor observed the resident's Foley catheter drainage bag hanging from the side of a chair or bed, fully visible from the doorway and to anyone passing by. Despite the presence of staff, including a Certified Nursing Assistant and a nurse, the drainage bag was not placed in a privacy cover. Interviews with staff, including a CNA, a nurse, and the Infection Preventionist, confirmed that the urine in the bag should not be visible to maintain the resident's dignity.
Deficiency in Catheter Care for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services for the care of an indwelling catheter for a resident, leading to a deficiency. The resident, who was admitted in May 2023, had diagnoses including urinary tract infection, bacteremia, difficulty in walking, and muscle weakness. The resident was dependent on staff for personal hygiene and had an indwelling Foley catheter. The facility's physician orders required Foley catheter hygiene every shift and specified that the catheter should be connected to a collection device at all times. During observations, the surveyor noted that the resident's urinary drainage bag was resting on the floor without a protective barrier, potentially exposing it to environmental contaminants. This was observed on two separate occasions, despite the facility's staff acknowledging that catheter bags should not be on the floor due to the risk of contamination. Interviews with a CNA, a nurse, and the Infection Preventionist confirmed that the catheter bag should not be on the ground, as it increases the risk of contamination.
Failure to Maintain Sanitary Conditions for CPAP Equipment
Penalty
Summary
The facility failed to maintain sanitary conditions for the CPAP equipment of a resident diagnosed with respiratory failure with hypercapnia. The resident, who is totally blind, reported that they could not verify if the CPAP machine and its components were being cleaned and stored properly. Observations revealed that the CPAP machine was covered in dust, and the tubing and mask were left exposed to potential contamination, rather than being stored in a protective bag as required. The equipment was found unlabeled and undated, and the resident expressed uncertainty about whether the cleaning and maintenance protocols were being followed. Interviews with staff, including a nurse and the Director of Nurses, confirmed that the CPAP equipment was not being maintained according to the facility's procedures. The nurse admitted uncertainty about the cleaning schedule and acknowledged that the equipment was not stored properly. The Director of Nurses confirmed that the equipment should be kept clean and stored in a respiratory storage bag when not in use, and acknowledged that the facility's expectations for maintaining the resident's respiratory equipment were not met.
Infection Control Lapses in PPE Usage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving residents. For Resident #51, staff did not adhere to the required personal protective equipment (PPE) protocols for Isolation/Droplet Precautions. Despite the presence of a sign indicating the need for full PPE, including an N95 respirator and eye protection, CNA #2 entered the resident's room wearing only a surgical mask, gown, and gloves, while CNA #6 entered without eye protection. This was observed despite the resident having tested positive for COVID-19 and being under isolation precautions. In another incident, Resident #13, who had chronic wounds and an indwelling urinary catheter, was on Enhanced Barrier Precautions (EBP). The facility's policy required staff to wear gloves and a gown for high-contact care activities. However, during an observation, CNA #1 entered the resident's room wearing only a surgical mask and gloves, and proceeded to reposition the resident without donning a protective gown, despite acknowledging the requirement for such precautions. Interviews with staff, including CNA #7 and the Infection Preventionist, confirmed the expectations for PPE use as per the facility's policies. The Infection Preventionist emphasized the necessity for staff to follow the posted PPE guidelines to prevent the transmission of multi-drug resistant organisms and COVID-19. These lapses in following established infection control protocols highlight the facility's failure to ensure compliance with its own policies and CDC guidelines, potentially compromising resident safety.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near North Attleboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Garden Place Healthcare | 3.8 mi | — | 10 | 0 |
| Mount St Rita Health Centre | 4.3 mi | — | 8 | 0 |
| Life Care Center Of Attleboro | 5.4 mi | — | 3 | 0 |
| Alliance Health At Maples | 5.5 mi | — | 6 | 0 |
| Grandview Center | 6.3 mi | — | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.