Madonna Manor
Madonna Manor in Villa Hills, KY — inspection on August 23, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
jeopardy to resident health or safety
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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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.