Madonna Manor

Medicare Outcome Measures

• Potentially preventable hospital readmissions

  10.40% (lower is better)

  No Different than the National Rate

• Residents discharged back to the community

  61.74% (higher is better)

  Better than the National Rate

• Infections acquired during the stay requiring hospitalization

  7.30% (lower is better)

  No Different than the National Rate

Source: CMS Skilled Nursing Facility Quality Reporting Program. Rates are risk-standardized by CMS; the comparison category is CMS's own, shown exactly as published.

Clinical Quality Measures

• Long-stay residents with a urinary tract infection

  1.3%

  national median 0.9%

  worse than the national median

• Long-stay residents experiencing falls with major injury

  8.6%

  national median 2.8%

  worse than the national median

• Short-stay residents who newly received an antipsychotic medication

  1.3%

  national median 1.0%

  worse than the national median

• Long-stay residents whose ability to walk independently worsened

  10.1%

  national median 12.5%

  near the national median

• Long-stay residents with pressure ulcers

  8.6%

  national median 4.2%

  worse than the national median

• Long-stay residents who received an antipsychotic medication

  15.1%

  national median 13.4%

  near the national median

Source: CMS MDS quality measures (four-quarter average).

Nurse Staffing

Nurse staffing per resident per day

6.8 hours

KY average: 4.0 hours · National: 3.9 hours

All nursing staff combined: RNs, LPNs/LVNs, and nurse aides.

Registered nurse (RN) time per resident per day

0.9 hours

KY average: 0.8 hours · National: 0.7 hours

RN hours only — the most highly trained nursing staff.

Weekend nurse staffing per resident per day

6.4 hours

KY average: 3.5 hours · National: 3.4 hours

Total nurse staffing on Saturdays and Sundays, when staffing typically dips.

Nursing staff turnover in the past year

63.3%

KY average: 46.4% · National: 45.8%

Share of this facility’s nursing staff who stopped working there over 12 months.

Reported by facilities through CMS's Payroll-Based Journal system. Facility values and the state/national averages are shown exactly as CMS publishes them. More staffing hours are generally better; lower turnover is generally better.

Penalties & Enforcement

2 fines totaling $181,278 in the recent inspection window (most recent: August 23, 2025).

Federal enforcement actions from CMS's penalty file: civil money penalties (fines) and denials of Medicare payment tied to health-inspection deficiencies.

Ownership

Ownership type

Non profit - Church related

Chain

Commonspirit Health