Inspection Reports for
Madonna Manor
2344 Amsterdam Rd, Villa Hills, KY 41017, United States, KY, 41017
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
34% worse than Kentucky average
Kentucky average: 4.7 deficiencies/year
Deficiencies per year
12
9
6
3
0
Inspection Report
Enforcement
Deficiencies: 1
Date: Aug 23, 2025
Visit Reason
The inspection was conducted due to an Immediate Jeopardy (IJ) related to the facility's failure to ensure resident safety by not effectively monitoring and preventing elopement for a high-risk resident.
Findings
The facility failed to have an effective system in place to ensure residents' safety, resulting in a high-risk resident eloping from the facility and being found outside unsupervised. Immediate Jeopardy was identified and later removed after the facility implemented corrective actions including reassessment of residents, staff education, and system audits.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and provide adequate supervision to prevent accidents, resulting in a high-risk resident eloping and being found outside unsupervised.
Report Facts
Residents affected: 1
Residents identified at risk: 18
Staff educated: 169
Distance resident eloped: 84
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Admitting Nurse | Named in disciplinary action for not applying Wander Gard to high-risk resident. |
| Security Officer 1 | Security Officer | Named in disciplinary action for resetting door alarm without perimeter check. |
| DON | Director of Nursing | Involved in interviews and corrective action planning. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 27, 2025
Visit Reason
The inspection was conducted following a complaint and investigation regarding the use of physical restraints on Resident 15, specifically the tying of a washcloth to the resident's wheelchair wheel, which led to a fall.
Complaint Details
The complaint involved Resident 15 being physically restrained by tying a washcloth to her wheelchair wheel by a Dining Aide. A State Trained Nurse Aide witnessed the restraint but failed to report it. The resident fell from the wheelchair but sustained no injuries. Both staff members were terminated. The facility's abuse reporting policy was not followed. The complaint was substantiated and corrected prior to the survey.
Findings
The facility failed to ensure Resident 15 was free from physical restraints and failed to implement the abuse policy properly. The Dining Aide tied a washcloth to the resident's wheelchair wheel, and a State Trained Nurse Aide witnessed but did not report the incident. Both employees were terminated. The facility provided an acceptable Plan of Correction and corrected the deficient practice before the survey.
Deficiencies (2)
F 0604: The facility failed to ensure each resident was free from physical restraints, as a washcloth was tied to Resident 15's wheelchair wheel, resulting in a fall. The facility corrected this practice before the survey.
F 0607: The facility failed to implement policies and procedures to prevent abuse and neglect, as a staff member tied a washcloth to Resident 15's wheelchair and another staff member failed to report it, leading to the resident's fall.
Report Facts
Residents Affected: 1
Staff Terminations: 2
Training Date: Jan 14, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dining Aide 1 | Dining Aide | Tied a washcloth to Resident 15's wheelchair wheel, causing a restraint and fall; terminated on 01/13/2025. |
| STNA13 | State Trained Nurse Aide | Witnessed the restraint but failed to report it; terminated on 01/15/2025. |
| Nurse 8 | Nurse | Assessed Resident 15 after the fall and found no injuries. |
| Administrator | Facility Administrator | Conducted investigation and stated facility policies on restraints and abuse reporting. |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Jan 3, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations related to resident care, medication administration, infection control, and facility operations.
Findings
The facility was found to have multiple deficiencies including failure to notify physicians of significant changes in residents' conditions, inadequate baseline care plans, medication administration errors, failure to prevent pressure ulcers, and lapses in infection prevention and control practices. Immediate Jeopardy was identified related to notification of changes, baseline care plans, quality of care, and medication administration but was removed after corrective actions.
Deficiencies (8)
F580: The facility failed to notify the physician of significant changes in condition for 2 residents, resulting in immediate jeopardy that was later removed.
F583: The facility failed to ensure resident privacy during medication administration for 1 resident.
F655: The facility failed to develop and implement baseline care plans within 48 hours for 2 residents, including interventions for infections and pressure ulcers, resulting in immediate jeopardy that was later removed.
F684: The facility failed to provide appropriate treatment and care according to orders and professional standards for 1 resident, including timely assessments and medication administration, resulting in immediate jeopardy that was later removed.
F686: The facility failed to provide appropriate pressure ulcer care and prevention for 1 resident, including failure to implement off-loading interventions and proper documentation.
F760: The facility failed to ensure residents were free from significant medication errors for 1 resident receiving IV antibiotic therapy, resulting in immediate jeopardy that was later removed.
F761: The facility failed to store medications securely and left an opened pharmacy delivery tote unattended on a medication cart.
F880: The facility failed to maintain an effective infection prevention and control program, including failure to wear appropriate PPE in isolation rooms and improper cleaning of shared glucometers for 2 residents.
Report Facts
Missed doses of cefepime: 4
Missed doses of metronidazole: 5
BIMS score: 14
BIMS score: 9
BIMS score: 15
BIMS score: 15
Pressure ulcer size: 5
Pressure ulcer size: 8
Pressure ulcer size: 0.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Named in failure to notify physician of resident condition change and failure to provide privacy during insulin administration. |
| RN2 | Registered Nurse | Named in failure to notify physician of resident condition change and failure to assess resident. |
| APRN | Advanced Practice Registered Nurse | Provided expert opinion on nursing responsibilities and infection control. |
| Medical Director | Provided expectations on nursing care and medication administration. | |
| PT Manager | Physical Therapy Manager | Observed wound changes and communicated with nursing staff. |
| IP/WCN | Infection Preventionist/Wound Care Nurse | Provided infection control education and wound care oversight. |
| DON | Director of Nursing | Involved in education and oversight of care plans and medication administration. |
| RN4 | Registered Nurse/Unit Manager | Provided statements on nursing rounding and documentation. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 23, 2024
Visit Reason
The inspection was conducted following complaints regarding the facility's failure to ensure residents' rights to dignified existence, self-determination, communication, and access to persons and services inside and outside the facility.
Complaint Details
The complaint investigation was substantiated based on interviews with family members, staff, and review of facility policies and communication records. Family members reported repeated unsuccessful attempts to contact the facility by phone, including calls going to full voicemail and unanswered calls. The facility acknowledged issues with phone communication and lack of designated staff to monitor messages.
Findings
The facility failed to ensure residents were treated with respect and dignity and had access to communication services. Family members reported multiple unsuccessful attempts to contact the facility via telephone due to unanswered calls and full voicemail boxes.
Deficiencies (1)
F 0550: The facility failed to ensure residents had the right to communicate and access persons and services inside and outside the facility. Family members of two residents reported inability to reach the facility by phone, with calls going unanswered or to full voicemail boxes.
Report Facts
Residents affected: 2
BIMS score: 15
BIMS score: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Mentioned as informing family about new telephone numbers. | |
| Licensed Practical Nurse (LPN) 2 | Reported difficulty reaching the Households by phone. | |
| Maintenance Director | Stated no recent changes to the phone system. | |
| Receptionist | Described call handling procedures and phone transfers. | |
| Administrator | Described phone system and expectations for communication. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 23, 2024
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to ensure residents' rights to communication, informed treatment participation, and proper immunization documentation.
Complaint Details
The investigation was complaint-driven, focusing on issues raised by family members about communication failures, refusal of COVID-19 testing, and missing immunization documentation. The complaints were substantiated with evidence from interviews, record reviews, and policy assessments.
Findings
The facility failed to ensure residents had access to communication via telephone, denied a resident's request for COVID-19 testing, and lacked documentation of influenza immunization or refusal for a resident. These issues affected a few residents and involved minimal harm or potential for harm.
Deficiencies (3)
F 0550: The facility failed to ensure residents were treated with dignity and had access to communication, as family members were unable to reach the facility by phone due to unanswered calls and full voicemail boxes.
F 0552: The facility failed to ensure residents were fully informed and participated in their treatment when staff refused to administer a COVID-19 test to a resident upon request.
F 0883: The facility failed to document administration or refusal of the influenza vaccine for a resident, lacking required immunization records for the 2023-2024 season.
Report Facts
Residents sampled: 22
Residents affected: 1
Residents affected: 2
Residents affected: 1
BIMS score: 15
BIMS score: 4
BIMS score: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| F4 | Family member who reported concerns about telephone communication and COVID testing refusal | |
| F5 | Family member who reported inability to reach facility by phone during resident's COVID illness | |
| F7 | Family member who reported refusal of COVID testing and communication issues | |
| DON | Director of Nursing | Provided information on telephone system, COVID testing policies, and immunization documentation |
| IP Nurse | Infection Preventionist Nurse | Provided information on COVID testing guidelines and immunization education |
| Administrator | Provided statements on facility expectations for communication, COVID testing, and immunization documentation | |
| LPN 2 | Licensed Practical Nurse | Reported difficulty reaching Household phones |
Inspection Report
Routine
Deficiencies: 5
Date: Oct 25, 2019
Visit Reason
Routine inspection survey conducted to assess compliance with resident rights, care planning, infection control, and call light system functionality at Madonna Manor nursing home.
Findings
The facility was found deficient in maintaining resident dignity and privacy, developing comprehensive care plans, ensuring infection prevention practices, and providing adequate call light systems. Specific issues included exposed catheter drainage bags, failure to revise care plans after falls, improper hand hygiene and gloving during meal service and medication administration, and insufficient phones for staff to respond to call lights.
Deficiencies (5)
F 0550: The facility failed to treat residents with respect and dignity, exposing Resident #49's catheter drainage bag and tubing in public areas and labeling Resident #53's socks with their name visible to others.
F 0656: The facility failed to develop and implement a comprehensive care plan for Resident #49's pressure ulcers, lacking interdisciplinary planning and measurable objectives.
F 0657: The facility failed to review and revise Resident #53's comprehensive care plan after multiple falls, omitting fall prevention interventions.
F 0880: The facility failed to maintain an effective infection prevention program, with staff observed not performing proper hand hygiene or wearing gloves during meal service and medication administration, and catheter drainage bags left on the floor.
F 0919: The facility failed to ensure a working call system in each resident's bathroom and bathing area, with insufficient phones for staff to be alerted to call lights, resulting in delayed response times.
Report Facts
Residents sampled: 24
Residents affected: 2
Urine volume in catheter bag: 125
Call light response time: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Charge Nurse of Household B | Named in infection control and catheter care findings |
| Interim Director of Nursing | Director of Nursing | Named in care plan and infection control findings |
| Administrator | Facility Administrator | Named in expectations for resident dignity and call light response |
| State Registered Nurse Assistant #4 | SRNA | Named in catheter care and infection control findings |
| State Registered Nurse Assistant #5 | SRNA | Named in catheter care and infection control findings |
| State Registered Nurse Assistant #6 | SRNA | Named in catheter care and infection control findings |
| Registered Nurse #1 | RN | Named in dignity and call light system findings |
| Licensed Practical Nurse #1 | LPN | Named in care plan and infection control findings |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Sep 14, 2018
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify physicians of significant weight loss, failure to provide care according to residents' plans, inadequate dementia care, and failure to provide pharmaceutical services as ordered.
Complaint Details
The investigation was complaint-driven focusing on failure to notify physicians of significant weight loss, failure to follow care plans, inadequate dementia care, and pharmaceutical service deficiencies. The complaints were substantiated with findings of minimal harm.
Findings
The facility failed to notify the physician and dietician of significant weight loss for Resident #50, failed to monitor and obtain weights as ordered for Resident #26, did not provide individualized dementia care plans for residents with dementia, and failed to obtain a prescription for Tramadol for Resident #28 resulting in the medication not being available.
Deficiencies (5)
F 0580: The facility failed to notify the physician and dietician of a significant 6.62% weight loss for Resident #50 between 08/25/18 and 09/09/18.
F 0659: The facility failed to provide care according to the written plan for Residents #50 and #26, including failure to monitor weight loss and notify appropriate staff.
F 0692: The facility failed to ensure residents maintained acceptable nutritional parameters for Residents #50 and #26, including failure to obtain weights as ordered and monitor weight loss.
F 0744: The facility failed to provide appropriate treatment and services for residents with dementia, lacking individualized care plans for Residents #1, #20, and #45.
F 0755: The facility failed to provide pharmaceutical services to meet resident needs for Resident #28 by not obtaining a handwritten prescription for Tramadol, resulting in the medication not being available.
Report Facts
Weight loss percentage: 6.62
Number of sampled residents: 18
BIMS score: 7
BIMS score: 14
BIMS score: 8
Medication dosage: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #5 | Licensed Practical Nurse | Interviewed regarding weight monitoring and notification procedures |
| RD | Registered Dietician | Interviewed about expectations for notification of weight changes |
| APRN | Advanced Practice Nurse Practitioner | Interviewed about expectations for notification of weight changes |
| DON | Director of Nursing | Interviewed about weight monitoring and notification responsibilities |
| Administrator | Interviewed about expectations for weight monitoring and pharmaceutical services | |
| SRNA #7 | State Registered Nurse Aide | Interviewed about weight obtaining responsibilities |
| SRNA #1 | State Registered Nurse Aide | Interviewed about weight obtaining responsibilities |
| LPN #1 | Licensed Practical Nurse | Interviewed about pain assessment and resident complaints |
| LPN #2 | Licensed Practical Nurse | Interviewed about medication order transfer and pharmacy communication |
| Facility Consultant Pharmacist | Interviewed about pharmacy not receiving Tramadol order | |
| Social Services Director | Interviewed about dementia care guidelines awareness |
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