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Madonna Manor

Non profit - Church related  ·  2344 Amsterdam Road, Villa Hills, KY 41017  ·  See home’s Medicare page

Inspections Delayed
The most recent standard inspection occurred more than two years ago. Inspections are supposed to occur every 18 months.
Affiliated With Commonspirit Health
People or companies with an ownership interest in or managerial control of this home, according to CMS data.
4.94
Nurse hours/resident/day
Reported total nurse staffing hours per resident per day.
State Average: 3.9
85.5%
Nurse turnover
The percentage of nursing staff who stopped working at the home over a 12-month period.
State Average: 54.1%
60
Certified beds
Qualifying beds in the certified provider or supplier facility.
54
Average residents/day
Average number of residents based on daily census.
Direct owners are the layer of ownership closest to the nursing home while indirect owners have a stake in the nursing home but are further removed, like a company that owns the direct owner of a home. All owners listed below are people or companies who have at least a 5% stake in the nursing home. Entities with “managerial control” are those who conduct the day-to-day operations of the nursing home.
Direct owners
Chi Living Communities (100%)
Indirect owners
Commonspirit Health (100%)
Sylvania Franciscan Health
Managerial control
No information available
Managing employee(s)
Denise Corrou since Sep, 2021

Inspection Reports

17

total deficiencies

3

infection-related deficiencies

This home violated federal standards protecting residents from the spread of infections.

Inspection reports document deficiencies, which are nursing homes’ failures to meet care requirements. The Centers for Medicare and Medicaid Services releases the last three standard inspection reports, as well as the last 36 months of complaint and infection-control reports.
Mar 4, 2021
Infection report
4 deficiencies
(2 infection)

This report includes a citation for violating federal standards protecting residents from the spread of infections.

E

Quality of Life and Care Deficiency — F0689
Failure to: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Pharmacy Service Deficiency — F0761
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Infection Control Deficiency — F0880
Failure to: Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Infection Control Deficiency — F0886
Failure to: Perform COVID19 testing on residents and staff.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Oct 25, 2019
Standard report
5 deficiencies
(1 infection)

This report includes a citation for violating federal standards protecting residents from the spread of infections.

D

to E
E

Infection Control Deficiency — F0880
Failure to: Provide and implement an infection prevention and control program.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Environmental Deficiency — F0919
Failure to: Make sure that a working call system is available in each resident's bathroom and bathing area.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Resident Rights Deficiency — F0550
Failure to: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0656
Failure to: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0657
Failure to: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Sep 14, 2018
Standard report
5 deficiencies
D

Resident Rights Deficiency — F0580
Failure to: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Resident Assessment and Care Planning Deficiency — F0659
Failure to: Provide care by qualified persons according to each resident's written plan of care.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0692
Failure to: Provide enough food/fluids to maintain a resident's health.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Quality of Life and Care Deficiency — F0744
Failure to: Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Pharmacy Service Deficiency — F0755
Failure to: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Dec 7, 2017
Standard report
3 deficiencies
D

to E
E

Pharmacy Service Deficiency — F0761
Failure to: 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.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Some people affected
Seriousness
E

Resident Assessment and Care Planning Deficiency — F0658
Failure to: Ensure services provided by the nursing facility meet professional standards of quality.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Pharmacy Service Deficiency — F0759
Failure to: Ensure medication error rates are not 5 percent or greater.
Severity
No actual harm, with a potential for more than minimal harm
Scope
Few people affected
Seriousness
D

Penalties

$35.7K

total fines

A nursing home receives a penalty, either a fine or payment suspensions, when it has a serious health citation or fails to fix a citation. Fines may be imposed once per citation or regularly until the nursing home corrects the citation. Fines not associated with inspection reports can include fines for not reporting COVID-19 data or not complying with infection-control requirements. Payment suspensions are when the government stops payments to the nursing home until an issue is fixed. The Centers for Medicare and Medicaid Services releases the last three years of penalty information.
Jan 3, 2022
No corresponding inspection report.
Dec 27, 2021
No corresponding inspection report.
Dec 20, 2021
No corresponding inspection report.
Dec 13, 2021
No corresponding inspection report.
Dec 6, 2021
No corresponding inspection report.
Nov 29, 2021
No corresponding inspection report.
Sep 27, 2021
No corresponding inspection report.
Sep 20, 2021
No corresponding inspection report.
Sep 13, 2021
No corresponding inspection report.
Sep 6, 2021
No corresponding inspection report.
Aug 30, 2021
No corresponding inspection report.
Aug 23, 2021
No corresponding inspection report.
Aug 16, 2021
No corresponding inspection report.
Aug 9, 2021
No corresponding inspection report.
Aug 2, 2021
$975 fine
No corresponding inspection report.
Jul 26, 2021
$655 fine
No corresponding inspection report.