Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Madonna Manor
Villa Hills, KY · 60 certified beds · Last Life Safety survey December 5, 2025
CMS Certification Number 185241 · first certified November 1990
Ownership
Operated by COMMONSPIRIT HEALTH · Non profit - Church related
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within KY
15 citations — more than 81% of the 267 certified nursing homes in KY. Compared within KY rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 7 citations; the earlier surveys in the window averaged 4. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens January 2027 — about 4 months from now. This facility’s last Life Safety survey was December 2025. Facilities in KY are typically surveyed 14–59 months after the last one (median 28), measured over 391 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 15 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 15 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in KY, and nationally. Surveyors differ markedly between states, so the KY figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 15 |
| Median facility in KY | 7 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| October 25, 2019 | 4 |
| August 23, 2024 | 4 |
| December 5, 2025 | 7 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2025-12-05 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-12-05 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2024-08-23 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2025-12-05 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2025-12-05 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 1 | 2025-12-05 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2025-12-05 |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | 1 | 2025-12-05 |
What the citations cover
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Smoke Deficiencies 4
- Egress Deficiencies 3
- Miscellaneous Deficiencies 1
- Other 2
| Category | Citations |
|---|---|
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Smoke Deficiencies | 4 |
| Egress Deficiencies | 3 |
| Miscellaneous Deficiencies | 1 |
| Services Deficiencies | 1 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
December 5, 2025 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (February 16, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (February 16, 2026) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (March 27, 2026) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (January 31, 2026) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (March 27, 2026) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (February 16, 2026) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (January 31, 2026) |
August 23, 2024 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0001 | Establish an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (November 22, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 21, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (October 21, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (October 21, 2024) |
October 25, 2019 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Deficient, Provider has date of correction (November 22, 2019) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (November 22, 2019) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (November 22, 2019) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (November 22, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.