Madonna Manor
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
care plans to ensure it reflects individual needs identified. Starting with new admissions after 8/13/2025 until substantial compliance is achieved. Newly hired employees will receive education on wandering, elopement, and resident safety by the DON/Nurse Managers in orientation starting 8/13/2025. An Adhoc QAPI with Medical Director, Director of Social Services, DON, and Executive Director was completed on 8/13/2025 to review QAPI plan created on 8/8/2025 Medical Director agrees with QAPI plan. DON/Nurse Managers will report results of audits, follow up and trends to QAPI committee on 8/22/2025 and will continue to report data to QAPI weekly for 4 weeks and then every other week until we are in substantial compliance. An Elopement Drill was held on 8/22/2025 at approximately 11:30am. An additional Elopement Drill will be held 8/22/2025 for night shift (after7pm) An Ad Hoc QAPI meeting is scheduled for 8/22/2025 at 8pm to discuss the results of the Elopement Drills and the IJ Abatement plan progress.Date facility alleges IJ removal: 8/23/2025
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Madonna Manor in Villa Hills, KY inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Villa Hills, KY, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Madonna Manor or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.