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The Pavilion at Kenton

401 East 20th Street, Covington, KY 41014 · For profit - Limited Liability company · 82 certified beds · (859) 283-6600 Medicare & Medicaid certified

Call the home — (859) 283-6600 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 24 lower-level deficiencies on record (see below)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (76%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★★★★ 5/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
401 E 20th St · (859) 292-4111 · Call to confirm hours
Pharmacy
40 Broadway St · (859) 823-0200 · Call to confirm hours
Grocery
1924 Eastern Ave
Park
Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 2 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased9.0%13.8%15.4%better
Long-stay residents who lose too much weight8.0%6.6%5.4%worse
Long-stay residents with a catheter left in their bladder0.3%0.5%0.9%better
Long-stay residents with a urinary tract infection0.0%1.6%2.0%better
Long-stay residents with depressive symptoms31.4%17.7%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury3.1%3.9%3.3%typical
Long-stay residents whose ability to walk worsened12.4%14.0%16.1%better
Long-stay residents on antianxiety or hypnotic medication31.4%29.8%18.9%worse
Long-stay residents given the seasonal flu vaccine90.8%96.2%95.3%typical
Long-stay residents with pressure ulcers3.0%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control11.9%19.0%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table19.4%16.1%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.8%1.7%1.4%worse
Short-stay residents given the seasonal flu vaccine54.5%83.5%79.4%worse
Short-stay residents rehospitalized after admission23.3%24.2%22.6%typical
Short-stay residents with an outpatient ER visit14.2%13.7%12.0%worse
Long-stay hospitalizations per 1,000 resident days3.791.941.67worse
Long-stay outpatient ER visits per 1,000 resident days3.302.141.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

31.9% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 32 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

31.9%U.S. median 51.5%
Got home and stayed home
12.8%U.S. median 10.7%
Went back to hospital
62.8%U.S. median 56.6%
Met the expected recovery
0.29U.S. median 0.31
Therapy hours / resident / day
0.10hours / resident / day
Physical therapy
0.11hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 62.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 43 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.29 therapist hours per resident per day in 2026Q1 — more than 45% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 44% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF31.9%CMS range 20.9–47.051.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.8%CMS range 9.5–17.710.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge62.8%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge60.5%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge55.8%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.5%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting88.2%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened3.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.0%CMS range 3.8–13.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.971.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.59
RN hours/ resident / day
0.69
LPN hours/ resident / day
1.58
Aide hours/ resident / day
2.85
Total nurse hours/ resident / day
0.49
RN hoursweekends
76.1%
Total nursing turnover
66.7%
RN turnover

How full it usually is: this home is certified for 82 beds and averages 77.8 residents a day — about 95% occupied, or roughly 4 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 2.85 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.59 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.58 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.59 hrs/resident/day on weekends vs 2.95 on weekdays — 12% thinner on weekends. RN hours go from 0.63 to 0.49 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 76% is well above the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

18
deficiencies at the latest standard inspection (2026-03-26)
3
at the previous standard inspection (2025-02-28)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

24 citations, most serious first. The 10 most serious are shown; the remaining 14 are one tap away and print in full.

  • Potential for harm · F2026-03-26 · tag F0725 — failed to have enough nursing staff — widespread
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, review of the Facility Assessment, and review of the facility's documents and policy, the facility failed to maintain sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population. Review of the facility's staffing for the past 30 days revealed the facility consistently failed to provide sufficient staff as determined in the Facility Assessment to ensure resident needs were met. The deficient practice had the potential to affect all 80 current residents.The findings Include:Review of the Facility Assessment, approved 12/10/2025, revealed staffing needs per shift for an average daily census of 74 were four to five nurses for day shift and four to five nurses for night shift. Continued…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-03-26 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of the facility's documents and policy, the facility failed to provide food and drink served at a safe and appetizing temperature to residents. The lunch test tray on 03/24/2026 revealed food items that were in the temperature danger zone range for both hot and cold foods. Resident attendees in the Resident Council meeting on 03/23/2026 stated they received cold food at mealtimes. Also, on 03/23/2026, Resident (R) 45 stated she received cold food all the time. This deficient practice had the potential to affect all 78 current residents that received food prepared in the kitchen. The findings include: Review of the facility's policy titled, Food Preparation and Service, dated 2001, revealed the temperature danger zone for food temperatures was above 41 degrees Fahrenheit (F) and below 135 degrees Fahrenheit (F). Per the policy, that temperature range promoted the rapid growth of pathogenic microorganisms that caused foodborne illness. The policy stated potentially hazardous foods must be maintained at or below 41 degrees F or at or above…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2026-03-26 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of the facility's policies, the facility failed to store, prepare, and serve food in accordance with professional standards for food safety. Observations revealed the nourishment refrigerators on the Purpose, Providence, and Honor Unit were not clean. In addition, opened but not dated food containers were observed on the Honor Unit and the kitchen, and the kitchen contained an item that was unrefrigerated which should have been refrigerated. The deficient practice had the potential to affect all 80 current residents. The findings include: Review of the facility's policy titled, Refrigerators and Freezers, dated 2001, revealed refrigerators and freezers were kept clean, free of debris, and disinfected with sanitizing solution on a scheduled basis and more often as necessary. Review of the facility's policy titled, Food Receiving and Storage, dated 2001, revealed all foods stored in the refrigerator or freezer were covered, labeled, and dated with use by date. Observation of the main dining room Honor Unit refrigerator on 03/22/2026 at 1:18…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-26 · tag F0550 — failed to protect resident dignity and rights — pattern
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and review of the facility's policy, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 9 of 15 residents participating in the Resident Council meeting, Resident (R) 3, R8, R9, R18, R43, R56, R68, R71, and R75.The findings include:Review of the facility's policy titled, Notice of Resident Rights, revised March 2018, revealed the facility shall inform the resident in writing of his or her rights as a resident, and the rules and regulations governing the resident's conduct and responsibilities during his or her stay in the facility.During observation of dinner on 03/22/2026 at 6:13 PM, all residents were being served their meal on Styrofoam plates, and they were eating with plastic silverware.During observation of lunch on 03/23/2026 at 12:37PM, all residents dining in the main dining room and the rehabilitation dining room were served their meals on…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-26 · tag F0576 — pattern
    Ensure residents have reasonable access to and privacy in their use of communication methods.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and review of the facility's policy, the facility failed to have a system in place for residents to send and receive mail, and to receive letters, packages, and other materials delivered to the facility on Saturdays for 15 of 15 residents participating in the Resident Council meeting, Resident (R) 3, R8, R9, R13, R15, R18, R37, R39, R43, R56, R66, R68, R71, R75, and R106.The findings include:Review of the facility's policy, Notice of Resident Rights, revised March 2018, revealed the facility shall inform the resident in writing of his or her rights as a resident, and the rules and regulations governing the resident's conduct and responsibilities during his or her stay in the facility.During the Resident Council meeting on 03/23/2026 at 2:00 PM, R3, R8, R9, R13, R15, R18, R37, R39, R43, R56, R66, R68, R71, R75, and R106 expressed their concern and frustration about the facility's failure to ensure they could send mail, letters, packages, and other materials, or receive items delivered to the facility on Saturdays. Specifically, R9, R37, and R43 all…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-26 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of facility policy, it was determined the facility failed to provide a safe, clean, comfortable and homelike environment.The findings include: Review of the facility's policy titled, Homelike Environment, last revised February 2021, revealed residents would be provided with a safe, clean, comfortable, and homelike environment, emphasizing independence and personal needs and preferences. Review of the facility's grievance logs for the previous six months revealed grievances from 12/17/2025 and 12/29/2025, expressing concerns about residents not having needed supplies, and about the small dining room remaining inaccessible. Although no resolution was documented regarding a supply issue, it was noted the facility was getting quotes for the small dining room repair. Additionally, a grievance dated 02/18/2026 noted a ceiling tile in the Honor dining room needed to be replaced and had a resolution of the tile being replaced. Review of the Resident Council minutes for the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-26 · tag F0585 — failed to handle grievances — pattern
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and review of the facility's policies, the facility failed to have information on how to file a grievance or complaint available to residents. In addition, the facility failed to establish a grievance system to ensure the prompt resolution of all grievances. The findings include:Review of the facility's policy titled, Notice of Resident Rights, revised March 2018, revealed the facility shall inform the resident in writing of his or her rights as a resident, and the rules and regulations governing the resident's conduct and responsibilities during his or her stay in the facility.Review of facility's policy titled, Grievances/Complaints, Filing, revised April 2017, revealed the residents and their representative have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the residents and/or representatives.During the Resident Council meeting on 03/23/2026 at 2:00 PM, residents…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-26 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of the facility's job description, and review of the facility's policy, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 6 of 25 sampled residents, Resident (R) 10, R11, R23, R32, R47, and R67. The care plans for R10, R11, R47, and R67 were not fully developed at admission to reflect their diagnoses. For R23 and R32, their care plans were fully developed, but staff did not implement the interventions in their care plans. The findings include: Review of the facility's policy titled, Care Plan, Comprehensive Person-Center, revised date 03/2022, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-26 · tag F0693 — failed to provide proper feeding-tube care — pattern
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of the manufacturer's guidance, and review of the facility's policies, the facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 6 of 6 residents sampled for enteral feeding, Resident (R) 32, R36, R38, R46, R50, and R78. Observations on 03/22/2026 and 03/23/2026 included tube feedings hanging that were not timed or dated with the connector tips without end caps; medications administered via the feeding tube without checking for placement prior to administration; and a tube feeding that was started two hours late and continued past the ordered stop time. In addition, R36 was sent to the Emergency Department on 07/02/2025 and 03/05/2026, after the adult day care center became concerned with the resident's gastrostomy tube status, and R36 was diagnosed with abdominal wall cellulitis without the facility's staff documenting the abnormal findings or…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-26 · tag F0699 — pattern
    Provide care or services that was trauma informed and/or culturally competent.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, review of the facility's job description, and review of the facility's policy, the facility failed to perform a trauma-informed care assessment for 5 of 5 residents sampled for trauma-informed care, Resident (R) 4, R10, R21, R67, and R75.The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person Centered, revision date 03/2022, revealed services would be provided or arranged by the facility and outlined in the Comprehensive Care Plan [CCP] that were trauma informed. Review of the facility's job description for Social Services Director, dated with a copyright of 2020, revealed the Social Services Director (SSD) was responsible for identifying and promoting individualized, non-pharmacological approaches to care that meet the mental and psychosocial needs of each resident. It also stated the SSD would ensure that residents who displayed mental illness or psychosocial difficulties would have access to appropriate treatment and resources.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · Ecited before2026-03-26 · tag F0761 — failed to label and store drugs safely — pattern
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of the facility's policy, the facility failed to ensure that medications were stored securely and remained inaccessible to unauthorized individuals for 3 of 4 medication carts observed that were unlocked and unattended.The findings include:Review of the facility's policy titled, Administering Medications, revised April 2019, revealed medications were to be administered in a safe manner, and medication carts were to be kept closed and locked when out of sight of the nurse. The policy further stated medications were not to be accessible to residents or others. 1. Observation on 03/22/2026 at 4:37 PM revealed Registered Nurse (RN) 1 placed Medication Cart 1 in the hallway outside a resident's room with the drawers facing the residents' common area near the nurses' desk, where residents were gathered. RN1 entered the resident's room to obtain a blood pressure, leaving the cart unlocked and unattended. The medication cart was out of view of RN1.In an interview with RN1 on 03/22/2026 at 4:50 PM, she stated she forgot to lock the medication cart…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-03-26 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) signage, and review of the facility's policies, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 12 of 25 sampled residents, Resident (R) 1, R3, R11, R18, R23, R32, R38, R47, R50, R66, R68, and R78. Observations on 03/22/2026, 03/23/2026, and 03/24/2026 revealed tube feedings hanging on poles but not timed or dated and without end caps, shared equipment not disinfected between resident use, residents on Enhanced Barrier Precautions (EBP) that had no signage for that on their room doors, and contaminated supplies placed on a surface without that surface being disinfected prior to placing uncontaminated items on it. The findings include: Review of the facility's policy titled, Infection Prevention and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2026-03-26 · tag F0925 — failed to control pests — pattern
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of the facility's documents and policy, the facility failed to maintain an effective pest control program to ensure the facility was free of pests and rodents. Observations on 03/22/2026 and 03/23/2026 revealed gnats in multiple areas of the facility. In addition, in interviews with residents and staff on 03/22/2026, 03/23/2026, and 03/24/2026, they reported seeing pests in the facility, including gnats, roaches, and mice. The deficient practice had the potential to affect all 80 current residents in the facility.The findings include: Review of the facility's policy titled, Homelike Environment, dated 2001, revealed residents were provided with a safe, clean, comfortable, and homelike environment. Review of the facility's contract with the pest control company, dated 10/16/2017, revealed pest coverage for mice, rats, spiders, centipedes, water bugs, silverfish, and roaches. Review of the pest invoices, dated 01/14/2026 to 03/02/2026, revealed the facility had a pest…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-26 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and review of the facility's policy, the facility failed to provide reasonable accommodation of resident needs and preferences for 1 of 25 sampled residents, Resident (R) 9.The findings include:Review of the facility's policy titled, Notice of Resident Rights, revised March 2018, revealed the facility shall inform the resident in writing of his or her rights as a resident, and the rules and regulations governing the resident's conduct and responsibilities during his or her stay in the facility.Review of R9's Face Sheet revealed the facility admitted the resident on 08/04/2022 with diagnoses to include generalized atherosclerosis, hypothyroidism unspecified, and major depressive disorder. Review of R9's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 08/04/2025, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 15 of 15, indicating little, if any, cognitive impairment.Review of R9's Care Plan, dated 03/17/2026, revealed the resident could shower two times a week and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-26 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's document and policy, the facility failed to notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood for 1 of 25 sampled residents, Resident (R) 46.During an interview on 03/25/2026 at 9:15 AM with the Regional Nurse, she stated the facility did not provide the representative with a reason for transfer in writing. She stated they made them aware verbally. The findings include:Review of facility policy titled Transfer or Discharge, Facility-Initiated, revised date of October 2022, revealed, The resident and representative are notified in writing of the following information: the specific reason for the transfer or discharge; the effective date of the transfer or discharge; the specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is being transferred or…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-26 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of the facility's policy, the facility failed to provide individualized and group activities that reflect the schedules, choices, and rights of the residents and to offer at the hours of convenience to the residents, including evenings, holidays, and weekends for 3 of 25 sampled residents, Resident (R) 36, R38, and R50. Observations on 03/22/2026, 03/23/2026, 03/24/2026, 03/25/2026, and 03/26/2026 revealed R36, R38, and R50 were either out of the facility to attend a school for the entirety of the day until approximately 4:30 PM or lying in bed. No observation of one-to-one activities was made, nor were these individuals observed out of bed or in group activity areas for socialization or participation.The findings include: Review of the facility's policy titled, Activity Programs, with a revision date of 06/2018, revealed the activity programs consisted of individual, small group, and large group activities that were designed to meet the needs and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-26 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, review of the facility's transfer agreement with the dialysis clinic, and review of the facility's policy, the facility failed to ensure residents who requires dialysis receive such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 sampled resident, Resident (R) 47. The facility was unable to provide evidence of communication with the dialysis center.The findings include:Review of the facility's policy titled, End Stage Renal Disease [ESRD], Care of a Resident With, last revised September 2010, revealed residents with ESRD would be cared for according to currently recognized standards of care. The policy further stated that assessments between the facility and the contracted ESRD facility included all aspects of how the resident's care would be managed. Review of the facility's Nursing Home Dialysis Transfer Agreement, dated 02/15/2010, revealed the facility would ensure that all appropriate medical, social, administrative, and other…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-26 · tag F0810 — isolated
    Provide special eating equipment and utensils for residents who need them and appropriate assistance.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of the facility's policy, the facility failed to provide assistive devices that facilitated residents' independence during meals in a manner that met the residents' individual needs for 1 of 25 sampled residents, Resident (R) 4. Observation on 03/22/2026 revealed R4 had his meal served on a glass plate instead of bowls to facilitate the resident's independence with his meal. The findings include:Review of the facility's policy titled, Assistance with Meals, revision date 03/2022, revealed, Adaptive devices (special eating equipment and utensils) will be provided for residents who need or request them. It also stated that assistance would be provided to ensure the residents can use and benefit from special eating equipment and utensils.Review of R4's admission Record revealed the facility originally admitted the resident on 10/04/2018 with the most recent re-admission date of 06/28/2023 with diagnoses which included major depressive disorder, severe protein-calorie malnutrition, and need for assistance with personal…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-02-28 · tag F0761 — failed to label and store drugs safely — widespread
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, review of the Food and Drug Administration article, and review of the facility's policy, the facility failed to ensure appropriate storage of residents' oral and topical medications, with multiple medications that were in use but exceeded the labeled expiration date. This occurred in 5 of 6 medication and treatment carts. The findings include: Review of the facility's policy, titled Medication Labeling and Storage, originally dated 2001 MED-PASS, revealed the facility stored all medications and biologicals in locked compartments under proper temperature, humidity, and light controls, and only authorized personnel had access to keys. Further review revealed the nursing staff was responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Continued review revealed if the facility had discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy was contacted for instructions regarding returning or destroying these items. Review of the Food and Drug Administration (FDA)…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-02-28 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of the facility's policies and isolation signage, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 18 sampled residents, Residents (R) 43, R58, R64, R68, and R78. Observation also revealed State Trained Nurse Aide (STNA) 1, STNA2, and STNA3 gave out lunch trays to residents without performing appropriate hand hygiene. The findings include: Review of the facility's policy titled, Infection Prevention and Control Program [IPCP], dated 12/2023, revealed members of the IPCP committee performed surveillance of staff adherence to IPCP practices. The policy stated the IPCP provided a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases, with the responsibility of coordination and oversight by the Infection Preventionist (IP). Further review revealed infection…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-02-28 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, review of the facility's documents, and review of the facility's policy, the facility failed to store food safely as determined by observations in the kitchen on 02/25/2025 at 10:30 AM and 02/27/2025 at 10:30 AM. The lunch tray carts contained pre-plated foods and drinks, which were not under refrigeration. Further, during the lunch meal service on 02/25/2025 at 12:12 PM Dietary staff touched different surfaces, but did not change gloves or wash hands. The findings include: Review of the facility's policy titled, Handwashing/Hand Hygiene, dated 10/2023, revealed the facility considered hand hygiene the primary means to prevent the spread of healthcare-associated infections. Per the policy, the use of gloves did not replace hand washing/hand hygiene. The policy stated hand hygiene was indicated immediately after glove removal and after touching the resident's environment. Review of the facility's document Meal Delivery Times, not dated, revealed lunch service for the Providence and Honor/Mental Disabilities Units was from 12:05 PM to 12:15 PM and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2021-07-15 · tag F0880 — failed to prevent and control infections — pattern
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, review of the facility's hand hygiene training program, and review of the facility's policy, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases, including COVID-19, and to implement interventions per the Centers for Medicare and Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), and the Kentucky Department for Public Health (Health Department) State guidelines for COVID-19. Observations, between 07/07/2021 and 07/15/2021, revealed multiple staff members not wearing personal protective equipment (PPE) appropriately while in the facility in patient care areas. Observation, on 07/08/2021, revealed dietary staff scraped food from plates and stacked contaminated plates, cups, and utensils onto a table where a resident remained eating dessert. Additional observation, on 07/08/2021, revealed dietary staff failed to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-07-15 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policies, it was determined the facility failed to have safeguards and systems in place to provide pharmaceutical services, to include procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for one (1) of eighteen (18) sampled residents (Resident #273). Review of Resident #273's hospital After Visit Summary (AVS) discharge orders, dated 06/02/2021, revealed four (4) medications were not transcribed from the AVS to Resident #273's Medication Order Summary, or acquired from the pharmacy. These four (4) medications were 1) Albuterol Sulfate HFA Aerosol Solution Inhaler as needed (PRN) (a bronchodilator used to treat wheezing and shortness of breath); Amitriptyline HCL (an antidepressant that could be used for insomnia); Diltiazem HCL (a calcium channel blocker or cardiac medication that could be used to control high blood pressure and control chest pain…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-07-15 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, it was determined the facility failed to adhere to accepted professional standards and practices, by maintaining complete and accurately documented resident records, for one (1) of eighteen (18) sampled residents (Resident #273). Review of Resident #273's hospital After Visit Summary (AVS) discharge orders, dated 06/02/2021, revealed the resident was ordered oxygen therapy at two (2) liters per minute to maintain an oxygen saturation (SpO2) between eighty-eight (88) and ninety-two (92) percent. Further review revealed the physician ordered SpO2 monitoring every shift. Review of Resident #273's medical record revealed the facility failed to transcribe a physician's order for oxygen therapy and document its administration on the Medication Administration Record (MAR). Additionally, the facility failed to transcribe the physician's order related to SpO2 monitoring every shift and failed to document the SpO2 assessment on the Treatment Administration Record (TAR). In addition, the facility failed to complete and accurately document Resident #273's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to THE PAVILION GROUP — 6 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 52.8-1.8 vs chain
Health inspection 1 of 52.8-1.8 vs chain
Staffing 1 of 51.8-0.8 vs chain
Quality measures 2 of 54.0-2.0 vs chain
The other 5 homes this chain runs (chain average 2.8★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
WILD CAT HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNFNO PERCENTAGE PROVIDEDsince 05/09/2017
WILDCAT HOLDING LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 05/09/2017
NIELK EQUITIES LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF25%since 05/09/2017
RAINLAND HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF5%since 01/01/2022
BERGER, DAVIDIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF20%since 05/09/2017
KLEIN, CHAIMIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST8%since 05/09/2017
KLEIN, GERSHONIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST8%since 05/09/2017
KLEIN, YISRAELIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST8%since 05/09/2017
LIEBERMAN, NECHEMIAIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; ADP OF THE SNF24%since 05/09/2017
THE PAVILION AT KENTON PROPERTY LLCOrganization5% OR GREATER MORTGAGE INTERESTsince 05/09/2017
MOERMAN, RAFAELIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/09/2017
FREY, CHRISTINAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/14/2025
KRIESER, AKIVAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 05/09/2017
CITRIN COOPERMAN ADVISORS LLCOrganizationADP OF THE SNFsince 05/09/2017
FASTEN HALBERSTAM LLPOrganizationADP OF THE SNFsince 05/09/2017
FULL MED STAFFING LLCOrganizationADP OF THE SNFsince 05/09/2017
GALE HEALTHCARE SOLUTIONS LLCOrganizationADP OF THE SNFsince 05/09/2017
MED-NET COMPLIANCE LLCOrganizationADP OF THE SNFsince 11/01/2018
OVATION REHABILITATION SERVICES LLCOrganizationADP OF THE SNFsince 05/09/2017
FAUGHN, LAURAIndividualADP OF THE SNFsince 01/02/2025

CMS files one row per role, so the 28 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted.

11 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$9.0M
Net patient revenuemost recent cost report
+2.1%
Operating marginrevenue minus expenses
$660K
Related-party expense8% of expenses
Who pays — share of resident-days
Medicaid 81%Medicare 8%Other / private 11%

About 81% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $660K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$328per resident / day
operating cost
$9,968per month
≈ monthly operating cost
$335per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in KY

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Kentucky Medicaid page.

Typical monthly cost in Kentucky
$9,718/mo
Nursing home (semi-private)
$11,254/mo
Nursing home (private)
$5,528/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 185038. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-26, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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