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38/100Madonna Manor Inspection Report, Violations & Safety Grade (Villa Hills, Kentucky)
2344 Amsterdam Road, Villa Hills, Kentucky 41017
Phone: 8594266400
CMS Overall:1/5
Overview & Bed Count
Certified Beds
60
Avg Residents/Day
53.6
Ownership
Non profit - Church related
Provider Type
Medicare and Medicaid
County
Kenton
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall1/5
Health1/5
Staffing4/5
Quality3/5
Nurse Staffing Check
| Metric | This Facility | Kentucky Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.85 | 0.80 | +0.05 |
| Total Nurse Hours per Resident per Day | 5.92 | 3.99 | +1.93 |
| CMS Staffing Rating | 4/5 | 2.8/5 | - |
| Nursing Staff Turnover | 57.7% | 45.4% | - |
Health Citation History
21 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-12-05 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2025-12-05 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2025-08-23 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2025-02-27 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | D – Moderate Harm Potential |
| 2025-02-27 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D – Moderate Harm Potential |
| 2025-01-03 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | J – Immediate Jeopardy |
| 2025-01-03 | Resident Assessment and Care Planning Deficiencies | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | J – Immediate Jeopardy |
| 2025-01-03 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | J – Immediate Jeopardy |
| 2025-01-03 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | J – Immediate Jeopardy |
| 2025-01-03 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G – Actual Harm |
| 2025-01-03 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2025-01-03 | Resident Rights Deficiencies | Keep residents' personal and medical records private and confidential. | D – Moderate Harm Potential |
| 2025-01-03 | Pharmacy Service Deficiencies | 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 locked, compartments for controlled drugs. | D – Moderate Harm Potential |
| 2024-08-23 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2024-08-23 | Resident Rights Deficiencies | Ensure that residents are fully informed and understand their health status, care and treatments. | D – Moderate Harm Potential |
| 2024-08-23 | Infection Control Deficiencies | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D – Moderate Harm Potential |
| 2019-10-25 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2019-10-25 | Environmental Deficiencies | Make sure that a working call system is available in each resident's bathroom and bathing area. | E – Moderate Harm Potential |
| 2019-10-25 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2019-10-25 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2019-10-25 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
Fire Safety Citation History
15 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-12-05 | Gas, Vacuum, and Electrical Systems Deficiencies | Have a battery powered remote alarm panel in a location accessible by operating personnel. | F – Moderate Harm Potential |
| 2025-12-05 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure that testing and maintenance of electrical equipment is performed. | F – Moderate Harm Potential |
| 2025-12-05 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | E – Moderate Harm Potential |
| 2025-12-05 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | D – Moderate Harm Potential |
| 2025-12-05 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | D – Moderate Harm Potential |
| 2025-12-05 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | D – Moderate Harm Potential |
| 2025-12-05 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | D – Moderate Harm Potential |
| 2024-08-23 | Emergency Preparedness Deficiencies | Establish an Emergency Preparedness Program (EP). | F – Moderate Harm Potential |
| 2024-08-23 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2024-08-23 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | F – Moderate Harm Potential |
| 2024-08-23 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | D – Moderate Harm Potential |
| 2019-10-25 | Egress Deficiencies | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | D – Moderate Harm Potential |
| 2019-10-25 | Egress Deficiencies | Have exits that are accessible at all times. | D – Moderate Harm Potential |
| 2019-10-25 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2019-10-25 | Miscellaneous Deficiencies | Have restrictions on the use of portable space heaters. | D – Moderate Harm Potential |
Total Penalties & Fines
$181,278
Total Fine Amount (CMS)
2
Number of Fines
2
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2025-08-23 | Fine | $19,145 | - |
| 2025-01-03 | Fine | $162,133 | - |
Need Help Finding Safe Care?
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(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the Villa Hills area at no cost.
Find Safe, Vetted Facilities Near Villa Hills
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.