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
Staffing
Hours and turnover
RN hours / resident day
1.12
Registered nurse staffing
LPN hours / resident day
0.64
Licensed practical nurse staffing
Aide hours / resident day
3.65
Nurse aide staffing
Weekend hours
4.78
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
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