Cycle 1
Health 2024-08-23 · Fire 2024-08-23
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Villa Hills, KY
Madonna Manor
1-star overall rating with 1-star inspections with $181,278 in total fines with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2344 Amsterdam Road, Villa Hills, KY
(859) 426-6400
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
55
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Commonspirit Health
Operator or chain grouping
Approved since
1990-11-07
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.12
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.64
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
3.65
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
5.42
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.77
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.78
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
1.04
CMS adjusted RN staffing hours
Adjusted total hours
5.04
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
5,733
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9889
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.88
Baseline 20.50% · Performance 19.63% · Measure score 3.88 · Achievement 3.88 · Improvement 1.99
Healthcare-associated infections
1.80
Baseline 5.83% · Performance 7.30% · Measure score 1.80 · Achievement 1.80 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
4.88
Baseline 4.92 hours · Performance 4.47 hours · Measure score 4.88 · Achievement 4.88 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.4% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 120 · Observed rate 9.17% · Lower 95% interval 7.39% |
| Discharge to community | 61.74% |
50.57%
11.2 pts better
|
Better than the National Rate · Eligible stays 103 · Observed rate 58.25% · Lower 95% interval 52.8% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.9% |
95.27%
3.6 pts better
|
Numerator 90 · Denominator 91 |
| Falls with major injury | 3.3% |
0.77%
2.5 pts worse
|
Numerator 3 · Denominator 91 |
| Discharge self-care score | 54.84% |
53.69%
1.2 pts better
|
Numerator 34 · Denominator 62 |
| Discharge mobility score | 61.29% |
50.94%
10.4 pts better
|
Numerator 38 · Denominator 62 |
| Pressure ulcers or injuries, new or worsened | 1.1% |
2.29%
1.2 pts better
|
Numerator 1 · Denominator 91 · Adjusted rate 1.09% |
| Healthcare-associated infections requiring hospitalization | 7.3% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 66 · Observed rate 7.58% · Lower 95% interval 4.57% |
| Staff COVID-19 vaccination coverage | 4.04% |
8.2%
4.2 pts worse
|
Numerator 9 · Denominator 223 |
| Staff flu vaccination coverage | 5.98% |
42%
36 pts worse
|
Numerator 18 · Denominator 301 |
| Discharge function score | 62.9% |
56.45%
6.4 pts better
|
Numerator 39 · Denominator 62 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 31 · Denominator 31 |
| Transfer of health information to patient | 97.5% |
96.28%
1.2 pts better
|
Numerator 39 · Denominator 40 |
| Resident COVID-19 vaccinations up to date | 45.1% |
25.2%
19.9 pts better
|
Numerator 23 · Denominator 51 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.9
0.6 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.2 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.2
0.8 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.2% |
94.3%
1.1 pts worse
|
93.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 92.3% · Q4 80.5% · 4Q avg 93.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.2%
3.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.5% |
3.8%
3.7 pts worse
|
3.3%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 7.3% · Q3 10.3% · Q4 7.3% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 67.8% |
15.2%
52.6 pts worse
|
11.4%
56.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 63.6% · Q2 74.4% · Q3 67.6% · Q4 64.9% · 4Q avg 67.8% |
| Percentage of long-stay residents who lose too much weight | 7.0% |
6.7%
0.3 pts worse
|
5.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 5.9% · Q3 12.9% · Q4 6.7% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.1% |
29.6%
11.5 pts better
|
19.6%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 15.8% · Q3 23.5% · Q4 15.2% · 4Q avg 18.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.2% |
17.6%
2.4 pts better
|
16.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 20.0% · Q3 9.1% · Q4 14.8% · 4Q avg 15.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.7% |
17.3%
4.6 pts better
|
16.3%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · 4Q avg 12.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.7% |
15.6%
1.9 pts better
|
14.9%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 13.9% · Q3 12.5% · Q4 16.1% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.7%
0.3 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.1% · Q4 2.2% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
1.7%
0.4 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.8% · Q4 2.6% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.5% |
19.8%
4.7 pts worse
|
19.8%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.1% · Q2 29.8% · Q3 22.0% · Q4 26.3% · 4Q avg 24.5% |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
5.5%
1.5 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 6.6% · Q3 6.2% · Q4 11.4% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 70.3% |
83.8%
13.5 pts worse
|
81.7%
11.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 87.7% · Q2 81.8% · Q3 66.4% · Q4 48.4% · 4Q avg 70.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.0% |
13.9%
3.9 pts better
|
12.0%
2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.0% · Observed 9.3% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.8%
1.2 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 1.1% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.7% |
83.6%
0.9 pts worse
|
79.7%
3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.2% |
24.5%
2.7 pts worse
|
23.9%
3.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.2% · Observed 25.3% · Expected 22.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-25 · Fire 2019-10-25
15 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2018-09-14 · Fire 2018-09-14
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-23
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2024-11-22
F · Potential for more than minimal harm
2024-08-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-21
F · Potential for more than minimal harm
2024-08-23
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-08-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-21
D · Potential for more than minimal harm
2019-10-25
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-11-22
D · Potential for more than minimal harm
2019-10-25
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2019-11-22
D · Potential for more than minimal harm
2019-10-25
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-11-22
D · Potential for more than minimal harm
2019-10-25
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2019-11-22
F · Potential for more than minimal harm
2018-09-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-10-19
D · Potential for more than minimal harm
2018-09-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2018-10-19
Inspection history
Recent health citations
J · Immediate jeopardy
2025-08-23
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-23
D · Potential for more than minimal harm
2025-02-27
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-02-01
D · Potential for more than minimal harm
2025-02-27
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-02-01
J · Immediate jeopardy
2025-01-03
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-02-01
J · Immediate jeopardy
2025-01-03
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-02-01
J · Immediate jeopardy
2025-01-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-01
J · Immediate jeopardy
2025-01-03
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-02-01
G · Actual harm
2025-01-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-01
E · Potential for more than minimal harm
2025-01-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-01
D · Potential for more than minimal harm
2025-01-03
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-02-01
D · Potential for more than minimal harm
2025-01-03
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-02-01
D · Potential for more than minimal harm
2024-08-23
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-08-23
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-10-21
D · Potential for more than minimal harm
2024-08-23
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-10-21
E · Potential for more than minimal harm
2019-10-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-12-13
E · Potential for more than minimal harm
2019-10-25
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2019-12-13
D · Potential for more than minimal harm
2019-10-25
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-12-13
D · Potential for more than minimal harm
2019-10-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-12-13
D · Potential for more than minimal harm
2019-10-25
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-12-13
D · Potential for more than minimal harm
2018-09-14
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2018-10-20
D · Potential for more than minimal harm
2018-09-14
F659 · Resident Assessment and Care Planning Deficiencies
Health
Provide care by qualified persons according to each resident's written plan of care.
Corrected 2018-10-20
D · Potential for more than minimal harm
2018-09-14
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2018-10-20
D · Potential for more than minimal harm
2018-09-14
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2018-10-20
D · Potential for more than minimal harm
2018-09-14
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2018-10-20
Penalties and ownership
What sits behind the stars
$19,145
2025-08-23
Fine
Fine · fine $19,145
Fine
$162,133
2025-01-03
Fine
Fine · fine $162,133
Fine
Ownership
Chi Living Communities
5% Or Greater Direct Ownership Interest · Organization
Brinson, Roger
Operational/Managerial Control · Individual
Cecil, Caitlin
Operational/Managerial Control · Individual
Cecil, Caitlin
Corporate Director · Individual
Chi Living Communities
Operational/Managerial Control · Organization
Commonspirit Health
5% Or Greater Indirect Ownership Interest · Organization
Commonspirit Health
Operational/Managerial Control · Organization
Corrou, Denise
Operational/Managerial Control · Individual
Dicon Health Services, Inc.
Operational/Managerial Control · Organization
Evans, Elaine
Operational/Managerial Control · Individual
Finn, Christina
Operational/Managerial Control · Individual
Finn, Christina
Corporate Director · Individual
Forvis Mazars Llp
Operational/Managerial Control · Organization
Grubbs, Stacey
Operational/Managerial Control · Individual
Grubbs, Stacey
Corporate Director · Individual
Hazard, Ted
Operational/Managerial Control · Individual
Hazard, Ted
Corporate Director · Individual
Howard, Casey
Operational/Managerial Control · Individual
Iffland, Alisa
Operational/Managerial Control · Individual
Iffland, Alisa
Corporate Officer · Individual
Kumar, Kelash
Operational/Managerial Control · Individual
Lipsey, Prentice
Corporate Officer · Individual
Longhin-Howard, Joan
Operational/Managerial Control · Individual
Lunsford, Dale
Operational/Managerial Control · Individual
Munroe, Kyle
Operational/Managerial Control · Individual
Munroe, Kyle
Corporate Director · Individual
Murriel, Shelly
Operational/Managerial Control · Individual
Murriel, Shelly
Corporate Director · Individual
Nagel, Jennifer
Operational/Managerial Control · Individual
Nagel, Jennifer
Corporate Director · Individual
Ohio Newspapers, Inc.
Operational/Managerial Control · Organization
Owens, Michele
Operational/Managerial Control · Individual
Prelude Systems, Inc.
Operational/Managerial Control · Organization
Reeves, Kellie
Operational/Managerial Control · Individual
Rehmer, Heather
Operational/Managerial Control · Individual
Rehmer, Heather
Corporate Officer · Individual
Skilled Care Pharmacy LLC
Operational/Managerial Control · Organization
Snodgrass, Barbara
Corporate Director · Individual
Soukup-Mcfarland, Dianne
Operational/Managerial Control · Individual
Sylvania Franciscan Health
5% Or Greater Indirect Ownership Interest · Organization
Temple, Pamela
Operational/Managerial Control · Individual
The Northern Trust Company
Operational/Managerial Control · Organization
Thomas, Linda
Operational/Managerial Control · Individual
Ulrichpinciotti Design Group, LLC
Operational/Managerial Control · Organization
Voelker, Jennifer
Operational/Managerial Control · Individual
Wine, Matthew
Operational/Managerial Control · Individual
Wine, Matthew
Corporate Director · Individual
Yelton, Mitzi
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Brookside Healthcare Center
Cincinnati, OH
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Village Care Center
Erlanger, KY
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Villaspring Of Erlanger
Erlanger, KY
3-star overall rating with 2-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Jump out