Madonna Manor
2344 Amsterdam Road, Villa Hills, KY 41017 · Kenton County · 60 certified beds · avg 55 residents/day · certified since Nov 7, 1990
Part of chain: COMMONSPIRIT HEALTH (18 facilities, chain avg rating 2.7★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Aug 23, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Sep 23, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Jan 3, 2025 · F-0580 · triggered by a complaint
The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Why it matters: A family could learn about a serious injury or decline days later, after the chance to act has passed.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Feb 1, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Jan 3, 2025 · F-0655 · triggered by a complaint
The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
Why it matters: In the critical first days, staff may not know a new resident's medications, diet, or fall risks.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Feb 1, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Jan 3, 2025 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Feb 1, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Jan 3, 2025 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Feb 1, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jan 3, 2025 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 1, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (21)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Dec 5, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Dec 5, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 23, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Feb 27, 2025 | D · Potential for harm, one-off | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint |
| Feb 27, 2025 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · from a complaint |
| Jan 3, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Jan 3, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint |
| Jan 3, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jan 3, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Jan 3, 2025 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Jan 3, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jan 3, 2025 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| Jan 3, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Aug 23, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Aug 23, 2024 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Aug 23, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Oct 25, 2019 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Oct 25, 2019 | E · Potential for harm, repeated | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. |
| Oct 25, 2019 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Oct 25, 2019 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Oct 25, 2019 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (3 → 2).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 5 | 0 | E |
| 2024 | 3 | 0 | D |
| 2025 | 13 | 6 | J ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $181,278.
| Date | Type | Amount / length |
|---|---|---|
| Aug 23, 2025 | Fine | $19,145 |
| Jan 3, 2025 | Fine | $162,133 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Kentucky avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.88 | 3.71 | 3.95 | top 11% in Kentucky; top 15% in the U.S. |
| Registered Nurse hours | 0.67 | 0.74 | 0.69 | top 45% in Kentucky; top 39% in the U.S. |
| Weekend total nurse staffing | 4.55 | 3.27 | 3.50 | top 11% in Kentucky; top 11% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.62 | 0.53 | 0.48 | top 26% in Kentucky; top 22% in the U.S. |
| Total nursing staff turnover (%) | 63.3 | 46.4 | 45.8 | bottom 9% in Kentucky; bottom 12% in the U.S. |
| RN turnover (%) | 56.3 | 41.8 | 42.9 | bottom 24% in Kentucky; bottom 26% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 6.85, RN 0.94, weekend 6.37. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: 3/5
Who owns this facility
Non profit - Church related
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Chi Living Communities | Organization | 5% or Greater Direct Ownership Interest | 100% | 11/01/2014 |
| Commonspirit Health | Organization | 5% or Greater Indirect Ownership Interest | 100% | 11/01/2014 |
| Sylvania Franciscan Health | Organization | Indirect Ownership Interest | NOT APPLICABLE | 11/01/2014 |
| Brinson, Roger | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/04/2022 |
| Cecil, Caitlin | Individual | Corporate Director | NOT APPLICABLE | 06/18/2012 |
| Cecil, Caitlin | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/08/2021 |
| Cecil, Caitlin | Individual | ADP of the SNF | NOT APPLICABLE | 06/18/2012 |
| Chi Living Communities | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/10/2017 |
| Chi Living Communities | Organization | ADP of the SNF | NOT APPLICABLE | 11/01/2014 |
| Commonspirit Health | Organization | Operational/Managerial Control | NOT APPLICABLE | 11/01/2014 |
| Commonspirit Health | Organization | ADP of the SNF | NOT APPLICABLE | 11/01/2014 |
| Concept Rehab, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 01/05/2015 |
| Corrou, Denise | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/30/2021 |
| Corrou, Denise | Individual | ADP of the SNF | NOT APPLICABLE | 04/17/2025 |
| Dicon Health Services, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 09/02/2022 |
| Dicon Health Services, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 04/07/2025 |
| Evans, Elaine | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/26/2022 |
| Finn, Christina | Individual | Corporate Director | NOT APPLICABLE | 07/01/2017 |
| Finn, Christina | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2017 |
| Finn, Christina | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2007 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Brookside Healthcare Center | 1.1 mi | Cincinnati, OH | ★★★★★ | 4/5 | |
| Village Care Center | 2.6 mi | Erlanger, KY | ★★★★☆ | 4/5 | |
| Villaspring of Erlanger | 3.6 mi | Erlanger, KY | ★★★☆☆ | 2/5 | |
| Bayley Place | 3.8 mi | Cincinnati, OH | ★★★★★ | 4/5 | |
| Ivy Woods Healthcare Center. | 3.9 mi | Cincinnati, OH | ★★★★☆ | 3/5 | |
| St Elizabeth Edgewood SNF | 4.2 mi | Edgewood, KY | ★★★★★ | 4/5 | |
| Delhi Post-Acute | 4.3 mi | Cincinnati, OH | ★☆☆☆☆ | 2/5 | |
| Aventura at West Park | 4.4 mi | Cincinnati, OH | ★☆☆☆☆ | 1/5 | |
| The Pavilion at Kenton | 4.5 mi | Covington, KY | ★☆☆☆☆ | 1/5 | |
| Edith Lane of Cincinnati | 4.5 mi | Cincinnati, OH | ★★☆☆☆ | 1/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 185241.