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Edgemont Healthcare

323 Webster Avenue, Cynthiana, KY 41031 · For profit - Limited Liability company · 68 certified beds · (859) 234-4595 Medicare & Medicaid certified

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Flagged for abuse3 actual-harm citations$133,225 in federal fines1 Medicare payment denial
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • CMS has flagged it for abuse
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Jul 2025
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 3 actual-harm citations
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $133,225 in federal fines (most recent 2025-07-25)
  • its independent health-inspection rating is low (1/5)
  • its payroll-based staffing rating is low (2/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (100%) 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) 2 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1210 KY Highway 36 E · (859) 234-9955 · Call to confirm hours
Pharmacy
430 E Pleasant St · (859) 234-6800 · Call to confirm hours
Grocery
304 S Church St · (859) 234-6064 · Call to confirm hours
Park
205 S Main St · 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 1 of 5
Long-stay residentspeople who live here 1 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 increased22.0%13.8%15.4%worse
Long-stay residents who lose too much weight1.7%6.6%5.4%better
Long-stay residents with a catheter left in their bladder0.3%0.5%0.9%better
Long-stay residents with a urinary tract infection5.7%1.6%2.0%worse
Long-stay residents with depressive symptoms0.4%17.7%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained2.0%0.2%0.1%worse
Long-stay residents with falls causing major injury3.5%3.9%3.3%typical
Long-stay residents whose ability to walk worsened14.6%14.0%16.1%typical
Long-stay residents on antianxiety or hypnotic medication31.7%29.8%18.9%worse
Long-stay residents given the seasonal flu vaccine94.2%96.2%95.3%typical
Long-stay residents with pressure ulcers5.3%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control15.8%19.0%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table42.7%16.1%17.1%worse
Long-stay hospitalizations per 1,000 resident days2.551.941.67worse
Long-stay outpatient ER visits per 1,000 resident days2.632.141.80worse

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.

0.23U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.23 therapist hours per resident per day in 2026Q1 — more than 28% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 28% 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 SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims 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 — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.891.02Oct 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

0.47
RN hours/ resident / day
0.41
LPN hours/ resident / day
2.04
Aide hours/ resident / day
2.92
Total nurse hours/ resident / day
0.38
RN hoursweekends
100.0%
Total nursing turnover
100.0%
RN turnover

How full it usually is: this home is certified for 68 beds and averages 65.9 residents a day — about 97% occupied, or roughly 2 beds typically open. It runs essentially full — expect a waiting list. 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 2.92 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.47 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.04 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 2.85 hrs/resident/day on weekends vs 2.95 on weekdays — 3% thinner on weekends. RN hours go from 0.50 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 100% is well above the national median of 45%. 1 administrator has left in the past year.

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 (2025-07-25)
3
at the previous standard inspection (2021-03-25)

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.

26 citations, most serious first. The 13 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · G2025-07-25 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility's policies, the facility failed to provide 2 (Resident (R) 54 and R10) of 21 sampled residents the right to reside and receive services with reasonable accommodation of the resident's needs and preferences except when to do so would endanger the health or safety of the resident or others. The facility moved or removed personal items, furnishings, and/or equipment without consideration of resident preferences and accommodation of each resident's individual needs. This failure caused R54 emotional distress over a sustained period of time and the resident was tearful as she related that the facility moved and mounted her television on the wall in a place where she had difficulty seeing it due to her physical limitations, as well as removed shelving that housed her personal collectibles. The findings include: Review of the facility's Homelike Environment Policy, revised 07/08/2023, revealed that it was the policy of the facility to provide a…

    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
  • Actual harm · Gcited before2025-07-25 · tag F0656 — failed to write and follow a full care plan — isolated
    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

    Based on observation, interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and/or mental and psychosocial needs identified in the comprehensive assessment for three (Resident (R)4, R46, and R36) of 21 sampled residents. The findings include:Review of the facility policy, Comprehensive Care Plans, dated 04/26/2017, revealed the facility was to develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights. Further review revealed the care plan was to include measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs.1.a. Review of Resident (R)4's admission Record revealed the facility admitted the resident on 05/18/2019. At this time, the resident had no pressure ulcers. Review of R4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/15/2024 revealed the resident was still free from pressure ulcers. 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2025-07-25 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of facility policy, the facility failed to provide treatment and services to prevent development of pressure ulcers for one (Resident (R) 4) of four residents reviewed for pressure ulcers. R4, who required staff assistance with turning and repositioning, was not care-planned with specific intervention for these services. The resident then developed a facility-acquired Stage III pressure ulcer in 01/2025. The Stage III pressure ulcer failed to heal as expected, and was present for 175+ days, as R4 failed to receive pressure relief as needed. The findings include:Review of R4's admission Record revealed the facility admitted the resident on 05/18/2019. Further review revealed her diagnoses at the time of the 07/25/2025 survey included unspecified dementia, neuromuscular dysfunction of the bladder, and a Stage III pressure ulcer of the right buttock. Per this face sheet, the pressure ulcer diagnosis was classified as occurring During Stay and was added to this face sheet on 06/10/2025,Review of R4's quarterly Minimum Data Set…

    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 · D2025-09-04 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    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 develop and implement policies and procedures that established a protocol for the determination of capacity to consent to sexual contact for 2 of 4 sampled residents, Resident (R) 4 and R13. Observations by staff on 07/27/2025 and 07/28/2025 revealed R4 and R13 were engaged in sexual behavior with one another. However, the facility's policy did not address the requirement to assess residents' capacity to consent to a sexual relationship and there was no evidence the facility assessed the residents for their capacity to consent to a sexual relationship.Additionally, the facility's policy failed to contain the eighth required component, in which the facility must coordinate situations of abuse with the Quality Assurance Performance Improvement (QAPI) program. The findings include:Review of the facility's policy titled, Abuse Investigation Policy Statement, dated 11/14/2016, revealed one of the seven components of the policy included prevention. Prevention was defined by identification,…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2025-07-25 · tag F0577 — widespread
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to post notice of the availability of the most recent survey results and failed to post those results in a place that was readily accessible to residents. The deficient practice had the potential to affect all residents' rights to be fully informed by being able to review that information upon request. The findings Include:Review of the facility's policy titled, Resident Rights, revised 04/12/2024, revealed residents have the right to receive all forms of communication while residing within the facility, and the facility would assist residents in exercising his/her rights.Observation during a tour of the facility on 07/22/2025 at 10:00 AM revealed there was no notice that indicated the location of the most recent state survey results and there was no visible physical account of the previous survey results.During an interview with the resident council on 07/22/2025 at 10:30 AM, they stated a majority of residents in attendance had never seen the facility's survey results. They stated they were not aware of 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 · F2025-07-25 · tag F0584 — failed to keep a safe, clean, comfortable home — widespread
    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, record review, and review of National Weather Service records, the facility failed to ensure each resident had a right to a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect all residents. The facility failed to promptly respond to problems with its cooling system and ensure that the facility was maintained at a safe, comfortable temperature, with temperatures in resident areas noted as high as 90 degrees Fahrenheit (F). The failure to provide safe, comfortable temperatures had the potential to affect all residents of the facility and constituted Substandard Quality of Care (SQC). In addition, multiple resident rooms (Rooms 209, 302, 317, and 320), a common resident gathering area, and the main dining hall needed repair and/or or cleaning. The findings include: In an interview with Ombudsman1 on 07/23/2025 at 9:32 AM, she stated she was first made aware that the facility's air conditioning (AC) was broken on 06/19/2025, which…

    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 · F2025-07-25 · tag F0838 — failed to assess facility resources and resident needs — widespread
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    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 assessment, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during day-to-day operations (including nights and weekends) and emergencies. The facility assessment failed to provide documented information to inform staffing decisions to ensure sufficient staffing to meet residents' needs for each shift and unit, develop and maintain a plan to maximize recruitment and retention of direct care staff, and inform contingency planning for events that did not require activation of the facility's emergency plan, but did have the potential to affect resident care, such as the availability of direct care nurse staffing or other resources for resident care. The deficient practice had the potential to affect all residents, with a census of 65.The findings include: Review of the facility assessment, dated 2025, revealed the facility failed to include information on how they determined the staffing levels needed for…

    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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2025-07-25 · tag F0725 — failed to have enough nursing staff — pattern
    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

    Based on observation, interview, staff time punch data, and Payroll Based Journal (PBJ) data, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets 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 the resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment. The deficient practice had the potential to affect all residents in the facility with a census of 65.The findings include: Review of the Payroll Based Journal (PBJ) for Fiscal Year Quarter 2, 01/2025 through 03/2025, revealed the facility triggered for one-star staffing and excessively low weekend staffing. Review of the facility's staffing agency invoices and the facility's document Calculated Time by Calendar Day, dated 02/01/2025 through 02/10/2025 revealed the facility was short of the Administrator's stated…

    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 · E2025-07-25 · 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, record review and facility policy review, the facility failed to properly label drugs and biologicals in accordance with currently accepted professional principles. They did not include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts. The findings include: Review of the facility's policy titled, Storage of Drugs and Biologicals, not dated, revealed that it was the policy of the facility that all drugs and biologicals be properly stored in the containers in which they were received. Further review revealed the policy did not mention dating opened multi use medications upon opening them. Observation on 07/22/2025 at 7:55 AM of the medication cart from the 100/200 Hallway labeled RN revealed the medication cart had seven bottles of eye drops, two inhalers, two bottles of cough syrup, two bottles of lactulose, two bottles of polyethylene glycol, and two bottles of nasal spray. Further review revealed all of these medications were opened without dates to when they were opened…

    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 before2025-07-25 · 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 and review of the facility's policy, 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. Review of the facility's Infection Control Plan policy, not dated, revealed the purpose of the infection control plan was to provide a safe, sanitary, and comfortable environment for all residents and staff. Review of the facility's Handwashing policy, not dated, revealed all personnel shall follow the established handwashing procedure to prevent the spread of infections and disease to other personnel, residents, and visitors. Wash hands for approximately 10-15 seconds, performed under the following conditions: h) After handling items potentially contaminated with blood, body fluids, excretions, or secretions: The use of gloves does not replace handwashing. 1. Observation of wound care for Resident (R)32 on 07/23/2025 at 1:30 PM revealed Registered Nurse (RN)1 and State…

    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 · E2025-07-25 · tag F0908 — failed to keep essential equipment working — pattern
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition. The mechanical lift scale was broken, and staff reported the lift function did not always work. The facility had 4 residents who used a Hoyer lift for weights.The findings include:Review of the lift company service invoice dated 07/02/2025 revealed the Field Service Technician found the cable to the scale on the lift had been cut. Further review revealed the Field Service Technician quoted a price to replace the scale.Review of the facility's document Nurse's Report Sheet, dated 07/23/2025 revealed staff could not obtain a weight for R53 due to the lift not working.Observation on 07/24/2025 at 10:05 AM revealed State Registered Nurse Aide (SRNA)4 demonstrated the scale function on the lift scale. Observation revealed the scale did not turn on so that residents could be weighed.In an immediate interview, SRNA4 stated the battery for the lift was fully charged, so that was not the cause of the malfunction. She stated it…

    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 · D2025-07-25 · tag F0550 — failed to protect resident dignity and rights — isolated
    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 observation, interview, record review, and facility policy review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 21 sampled residents, Resident (R)4 and R36.The facility failed to ensure R36's visual privacy while she was undressed.The facility failed to ensure R4's catheter collection bag was covered.The findings include:Review of the facility's policy, Resident Rights, dated 04/12/2024, revealed the facility was to protect and promote the right of each resident to a dignified existence. Further review revealed the facility would provide an environment that enhanced the resident's quality of life and recognized the resident's individuality.1) Review of R36's admission Record revealed the facility admitted the resident on 05/21/2018. Further review revealed her diagnoses included Huntington's disease (a severe neurological disorder), Alzheimer's disease, restless leg…

    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 · D2025-07-25 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and facility policy review, the facility failed to protect the resident from misappropriation of property for 2 of 2 residents investigated for personal property. Resident (R) 24 and R10 filed grievances for missing clothing, but the facility failed to reimburse the residents for their missing items.The findings include:Review of the facility's document, Notice of Resident Rights and Responsibilities, dated 03/27/2024, revealed residents had the right to keep and use their personal belongings, and to have the facility protect their property from theft.1) Review of R24's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/30/2025 revealed the facility admitted the resident on 06/02/2021. Further review revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Continued review revealed R24 responded Very Important when asked how important it was to her to take care of her personal belongings.Review of the facility's form…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2025-07-25 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure residents' assessments accurately reflected the resident's status for 1 of 21 sampled residents. The findings include: Review of R30's Face Sheet revealed the facility admitted R30 on 06/14/2022 with diagnoses that included unspecified congenital malformation of limbs, anemia unspecified, and obesity unspecified. The diagnosis type II diabetes mellitus was added on 01/14/2025. R30 was ordered Lispro 100 unit/1ml (milligram) insulin pen sliding scale before meals on 01/19/2025. R30 also received orders for Lantus Solstar Pen 100 unit/1ml insulin pen 60 units twice a day on 03/15/2025. Review of R30's Annual MDS (Minimum Data Set) dated 05/23/2025 revealed R30 was coded in Section N0300, Injections, as having no injections during the seven-day look back period. Review of Section N0350, Insulin, revealed R30 as not having any documented injections in the seven-day look back period. Review of R30's MAR dated 05/2025 revealed R30 received Lispro, although the lunch (11:30 AM) and dinner (4:30 PM) doses were cancelled as…

    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 · D2025-07-25 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure the comprehensive care plan was revised following an incident for 1 of 21 sampled residents. Resident (R)2 suffered a fall on 01/24/2025 resulting in injury; however, R2's comprehensive care plan was not revised following the fall. The findings include: Review of R2's Face Sheet revealed the facility admitted R2 on 06/26/2024 with diagnoses that included encephalopathy unspecified, unspecified dementia without behavioral disturbance, and unspecified malignant neoplasm of the skin. Review of 12/23/2024 Quarterly Minimum Data Set (MDS) assessment, revealed the facility assessed R2 as 13/15 on a Brief Interview for Mental Status (BIMS), indicating intact cognition. Further review revealed the facility assessed R2 as independent with a wheelchair for mobility and required supervision with transfers. The assessment further noted R2 had not had any falls since admission. Review of a Progress Note, dated 01/24/2025 at 5:00 PM revealed a resident across the hall from R2 alerted a nurse that R2 was on the floor in her room.…

    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 · D2025-07-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, the facility failed to provide services to dependent residents to maintain good personal hygiene for 1 of 5 residents investigated for activities of daily living (ADL) care, Resident (R)46. The findings include:Review of R46's admission Record revealed the facility admitted the resident on 09/24/2024 with diagnoses that included spastic hemiplegia (muscle stiffness and spasms) of the left dominant side, need for assistance with personal care, and anxiety disorder.Review of R46's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/23/2025 revealed the facility assessed the resident with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident was cognitively intact. Further review revealed the facility assessed the resident as dependent on staff for toileting hygiene.Review of R46's Comprehensive Care Plan (CCP) dated 10/25/2024 revealed the facility assessed R46 as dependent with toileting hygiene. Further review revealed interventions included to assist the resident as…

    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 · D2025-07-25 · 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

    Based on observation, interview, record review, and facility policy review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group activities and individual activities, designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 1 of 1 residents investigated for activities, Resident (R) 36. Observations throughout survey revealed R36 sitting alone in her room, awake, with no television, music, or other form of stimulation available to her.The findings include:Review of the facility policy, Activities and Social Events, not dated, revealed the facility expectation was for all residents to choose the types of activities in which they wished to participate. Further review revealed the facility was to develop activities schedules based on resident preferences and in conjunction with their plan of…

    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 · D2025-07-25 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review and facility policy review, the facility failed to provide services to prevent urinary tract infections for 1 of 2 residents with an indwelling catheter, R4. Observations throughout survey revealed R4's catheter tubing and catheter bag dragging the ground under her wheelchair.The findings include:Review of the facility's policy Indwelling Catheter Use, dated 05/14/2006, revealed the policy did not address a protocol for the care of urinary catheters to include measures to prevent infections, including steps for cleaning the catheter, and instructions for maintenance of the collection system.Review of Resident (R)4's admission Record revealed the facility admitted the resident on 05/18/2019. Further review revealed R4's diagnoses included unspecified dementia, neuromuscular dysfunction of the bladder, and stage three pressure ulcer of the right buttock.Review of R4's Comprehensive Care Plan (CCP), dated 04/18/2025 revealed the facility identified R4 as needing an indwelling urinary catheter and included the interventions related 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-07-25 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policies, the facility failed to ensure residents requiring dialysis received services consistent with professional standards of practice by failing to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 1 of 3 residents reviewed for dialysis, Resident (R)3. Record review and interview revealed the facility failed to obtain or document R3's post dialysis center vital signs, weight and pertinent report information following dialysis visits. Further review revealed the facility failed to provide communication to the dialysis facility for pre-dialysis vital signs, medications and pertinent changes. The findings include:Review of the facility's policy Care of Residents on Dialysis, not dated, revealed the facility shall maintain ongoing communication and collaboration with the dialysis facility regarding dialysis care and services to ensure the resident's needs were met. Further review…

    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 · E2021-03-25 · 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 U.S. Food and Drug Administration Food Code, 2017, and review of the facility's policies, it was determined the facility failed to store food in accordance with professional standards for food service safety. The findings include: Review of the U.S. Food and Drug Administration Food Code, 2017, Subpart 3-602, Food Labels, revealed packaged food must include the common name of the food, or absent a common name, an adequately descriptive identity statement. In addition, the code stated another form of information on the food label would be unconcealed or unaltered dating information. Review of the facility's policy titled, Food Storage, undated, revealed it was the policy of the facility to store, label, and date food properly and safely. In addition, the policy stated food would be correctly labeled with the name of the food item, the date of storage, and stored properly according to food safety guidelines. Review of the facility's policy titled, Food Brought in From Outside Sources, undated, revealed outside foods or beverages brought…

    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 · D2021-03-25 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    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 policy, it was determined the facility failed to protect residents from abuse for one (1) of sixteen (16) sampled residents, Resident #16. Resident #16 was struck in the face by Resident #24. The findings include: Review of the facility's policy titled, Prevention and Reporting of Resident Abuse, revised 11/14/2016, revealed the facility was committed to protecting residents from abuse by anyone, including other residents, and revealed the facility did not condone abuse by anyone. Review of the facility's Initial Self-Reported Incident Form, dated 03/21/2021, revealed an allegation of resident-to-resident abuse, observed by Registered Nurse (RN) #1 and the Director of Nursing (DON), on 03/21/2021, who saw Resident #24 strike Resident #16 in the face. Review of the Facility Investigation File, dated 03/21/2021, revealed Resident #16 was physically abused by Resident #24, on 03/21/21 at 12:30 PM, when Resident #24 struck Resident #16 in the face,…

    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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-03-25 · tag F0813 — isolated
    Have a policy regarding use and storage of foods brought to residents by family and other visitors.
    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, it was determined the facility failed to store food delivered from an outside source in accordance with professional standards of food service. The findings include: Review of the facility's policy titled, Food Brought in From Outside Sources, undated, revealed special circumstances could require that food be brought into the facility from the outside. Per policy, these outside foods or beverages would be labeled with the resident's name and dated by the receiving dietary staff with the current date the item(s) was brought to the facility for storage. The policy also stated that food or beverage items could be stored in facility pantries, refrigerators, or freezers. Observations completed during the initial kitchen tour, on 03/23/2021 at 9:12 AM, revealed two (2) commercial pizza boxes in the kitchen refrigerator, one (1) large box and one (1) smaller box. The large box contained pizza but was not marked with a resident name or date of receipt. The smaller box contained two (2) cinnamon rolls and had 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-03-07 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of facility Policy, it was determined the facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents, staff and the public. Observation on 03/05/19, revealed sewage in the basement area where the dry goods were located. The findings include: Review of the facility's Food Storage Policy, undated, revealed food will be properly stored to preserve flavor, nutritive value, appearance and safety. Observation of the facility basement on 03/05/19 at 10:30 AM, revealed dry goods and a pantry area. Further observation revealed there was evidence of a sewage spill (toilet paper and fecal matter) discovered in the boiler room floor at the bottom of the stairs near the dry goods and pantry area. The space also contained an open sump pump well that was observed to contain dirty and possibly sewage contaminated water. This space was open to the corridor that was in regular use by kitchen staff when getting food items from the pantry area, located in the basement. Interview on 03/05/19 at 10:30 AM, with the Director…

    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 · Dcited before2019-03-07 · tag F0656 — failed to write and follow a full care plan — isolated
    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

    Based on observation, interview, record review, review of facility Policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to develop and implement a comprehensive person centered care plan for each resident, that includes measurable objectives and timeframes to meet the resident's medical and nursing needs for one (1) of nineteen (19) sampled residents (Resident #22). Although Resident #22's Annual Minimum Data Set (MDS) Assessment, dated 07/17/18, and Quarterly MDS Assessment, dated 01/08/19, revealed the resident had Functional Limitations in Range of Motion for bilateral upper and lower extremities, there was no documented evidence the Comprehensive Care Plan was developed and implemented to address the resident's limited range of motion/contractures. (Refer to F-688) The findings include: Review of the facility Policy titled, Comprehensive Care Plans revised 04/26/17, revealed the Comprehensive Care Plan would reflect resident needs identified in the comprehensive assessment.…

    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 · D2019-03-07 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review, and review of facility Policy, it was determined the facility failed to provide services to increase or prevent further decrease in range of motion for one (1) of nineteen (19) sampled residents (Resident #22). Although Resident #22 had Functional Limitations in Range of Motion (ROM), record review and staff interview, revealed the resident was not receiving services to increase ROM and/or to prevent further decrease in ROM. (Refer to F-656) The findings include: Review of the facility Policy titled, Restorative Nursing Care undated, revealed the facility was to provide every resident with restorative nursing care. Review of Resident #22's medical record revealed the facility admitted the resident on 07/05/17 with diagnoses to include Congenital Hydrocephalus, Malignant Neoplasm of the Lung, Anxiety Disorder, Unspecified Intellectual Disability, and Reduced Mobility. Review of the Resident-Date Collection document, dated 07/05/19, completed on admission, revealed the resident had bilateral hand and foot deformities. There was no…

    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 · Dcited before2019-03-07 · tag F0880 — failed to prevent and control infections — isolated
    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, review of facility Policies, and review of the Centers for Disease Control (CDC) Guideline for Hand Hygiene in Healthcare Settings, Volume 51, published 10/25/02, 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 the development and transmission of communicable diseases and infections for two (2) of nineteen (19) sampled residents (Resident #25 and Resident #38). Observation on 03/05/19, revealed Registered Nurse (RN) #1 did not perform hand prior to or post administration of medication for Residents #25 and #38. In addition, RN #1 handled pills with her bare hands prior to administering the medication to these residents. The findings include: Review of the facility Policy titled, Brainwashing undated, revealed all personnel should perform handwashing procedures to prevent infection transmission before preparing or handling medications. Review of the facility Policy titled, Administration of…

    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

“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

$133,225 in federal fines across 1 penalty. 1 Medicare payment denial on record.

  • $133,225 — penalty dated 2025-07-25
  • Medicare payment denial — starting 2025-08-26 for 37 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleShareSince
HAEFER, BONNIEIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR; CORPORATE OFFICER33%since 09/15/2005
MITCHELL, KERRIEIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR33%since 10/25/2005
MOORE, ERNESTIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST; W-2 MANAGING EMPLOYEE; CORPORATE DIRECTOR33%since 10/25/2005

CMS files one row per role, so the 10 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$5.0M
Net patient revenuemost recent cost report
-2.4%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 92%Medicare 2%Other / private 6%

About 92% 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.

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

$223per resident / day
operating cost
$6,782per month
≈ monthly operating cost
$218per 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 185389. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-25, 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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