01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-12-05 | 3 | 2025-12-05 | 7 |
| Cycle 2 | 2024-08-23 | 13 | 2024-08-23 | 4 |
| Cycle 3 | 2019-10-25 | 5 | 2019-10-25 | 4 |
CMS CCN 1852412026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Madonna Manor
2344 Amsterdam Road · Villa Hills, KY 41017 · Kenton County
Certified beds60CMS provider file
Recent citation rows36current CMS citation release
Penalty rows2current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
36 rows in the current release
6 rows carry G–L scope/severity codes; 5 carry J–L. 4 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-12-05 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2026-01-192025-12-05 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-01-192025-12-05 · FIREK0211Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has date of correction · 2026-02-162025-12-05 · FIREK0353Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2026-02-162025-12-05 · FIREK0363Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2026-03-272025-12-05 · FIREK0916Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Correction field: Deficient, Provider has date of correction · 2026-01-312025-12-05 · FIREK0920Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Correction field: Deficient, Provider has date of correction · 2026-03-272025-12-05 · FIREK0921Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure that testing and maintenance of electrical equipment is performed.
Correction field: Deficient, Provider has date of correction · 2026-02-162025-12-05 · FIREK0923Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Correction field: Deficient, Provider has date of correction · 2026-01-312025-08-23 · HEALTHF0689Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-09-23 · complaint2025-02-27 · HEALTHF0604Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Correction field: Past Non-Compliance · 2025-02-01 · complaint2025-02-27 · HEALTHF0607Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Correction field: Past Non-Compliance · 2025-02-01 · complaint2025-01-03 · HEALTHF0580Severity J · isolated immediate jeopardy
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.
Correction field: Deficient, Provider has date of correction · 2025-02-01 · complaint2025-01-03 · HEALTHF0583Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Keep residents' personal and medical records private and confidential.
Correction field: Deficient, Provider has date of correction · 2025-02-01 · complaint2025-01-03 · HEALTHF0655Severity J · isolated immediate jeopardy
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
Correction field: Deficient, Provider has date of correction · 2025-02-01 · complaint2025-01-03 · HEALTHF0684Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-02-01 · complaint2025-01-03 · HEALTHF0686Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2025-02-01 · complaint2025-01-03 · HEALTHF0760Severity J · isolated immediate jeopardy
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2025-02-01 · complaint2025-01-03 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-02-01 · complaint2025-01-03 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-02-01 · complaint2024-08-23 · FIREE0001Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Establish an Emergency Preparedness Program (EP).
Correction field: Deficient, Provider has date of correction · 2024-11-222024-08-23 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2024-10-21 · complaint2024-08-23 · HEALTHF0552Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Correction field: Deficient, Provider has date of correction · 2024-10-212024-08-23 · HEALTHF0883Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Correction field: Deficient, Provider has date of correction · 2024-10-2103 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-08-23 | Fine | $19,145 | 0 |
| 2025-01-03 | Fine | $162,133 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- CHI LIVING COMMUNITIESOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 11/01/2014
- COMMONSPIRIT HEALTHOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST100% · since 11/01/2014
- SYLVANIA FRANCISCAN HEALTHOrganization · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 11/01/2014
- LIPSEY, PRENTICEIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 11/01/2021
- MBANU, TERIKAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/05/2024
- MELFI, MITCHIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 05/23/2016
- CECIL, CAITLINIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 06/18/2012
- FINN, CHRISTINAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 07/01/2017
- GRUBBS, STACEYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 03/06/2021
- HAZARD, TEDIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/08/2017
- MUNROE, KYLEIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 09/08/2015
- MURRIEL, SHELLYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 09/09/2024
- NAGEL, JENNIFERIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 11/12/2015
- SNODGRASS, BARBARAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 08/15/2016
- WINE, MATTHEWIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 10/01/2018
- IFFLAND, ALISAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/06/2017
- LIPSEY, PRENTICEIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/01/2022
- REHMER, HEATHERIndividual · CORPORATE OFFICERNOT APPLICABLE · since 06/25/2024
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours6.85per resident day
RN hours0.94per resident day
Weekend nurse hours6.37per resident day
Staff turnover63.3%CMS reported field
06 / LOCAL RECORDS
Open the Kentucky ledger →Other published facilities nearby
No second facility in the same city met the directory rule.