Madonna Manor: Wound Notification Failure Cited - KY
When a wound care physician finally examined the resident on October 23, five days later, the provider documented what was there: an unstageable deep tissue injury measuring 5.0 centimeters long, 8.0 centimeters wide, and 0.1 centimeters deep, caused by pressure. An unstageable wound is one so covered in dead tissue or slough that its full depth cannot be determined. The damage underneath may be far worse than what is visible at the surface.
Federal inspectors, reviewing the facility's records during a complaint inspection completed January 3, 2025, found that nursing staff had failed to notify the physician of a change in condition immediately after the wound was discovered. They rated the violation at the highest level of harm: immediate jeopardy to resident health or safety.
The gap between discovery and physician notification is the center of what inspectors found. Physical therapy staff located the wound. Nursing was informed. A progress note from the wound care physician, dated five days after that discovery, is where the formal medical record of the injury begins. What happened in the days between those two moments, the inspection report does not fully describe. What it does say is that the notification that should have happened immediately did not.
Madonna Manor is a nursing facility at 2344 Amsterdam Road in Villa Hills, a small city in Kenton County just south of Cincinnati. The inspection was triggered by a complaint, not a routine survey.
An unstageable wound to the heel carries particular risk. The heel has little protective tissue between skin and bone. Pressure injuries in that location can deteriorate rapidly, and without timely medical intervention, what begins as deep tissue damage can progress to exposed bone or systemic infection. The five days between the physical therapist's discovery and the wound care physician's documented assessment represent the window inspectors found most troubling.
The wound care physician's note, dated October 23, described the injury as newly acquired. The cause was listed as pressure. At 5.0 by 8.0 centimeters, the wound was roughly the size of a playing card.
Inspectors classified the deficiency under F580, which covers a facility's obligation to notify a resident's physician and, where applicable, the resident's representative when there is a change in condition that requires a physician's attention. The immediate jeopardy designation means inspectors determined the failure placed the resident in a situation where serious injury, harm, or death was possible.
The inspection report identifies the resident only as R2. It does not describe what treatment was ultimately provided, whether the wound worsened during the five-day gap, or what condition the resident was in when the wound care physician arrived.
What the record shows is a wound found on a Friday, and a physician's note written the following Wednesday.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Madonna Manor from 2025-01-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 6, 2026 · Our methodology
Madonna Manor in Villa Hills, KY was cited for violations during a health inspection on January 3, 2025.
An unstageable wound is one so covered in dead tissue or slough that its full depth cannot be determined.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.