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Dover Nursing & Rehabilitation Center

112 Dover Drive, Georgetown, KY 40324 · For profit - Limited Liability company · 85 certified beds · (502) 863-9529 Medicare & Medicaid certified

Call the home — (502) 863-9529 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Dec 2023Behavioral-health or dementia-care citation — no harm found (F0740)1 actual-harm citation$163,742 in federal fines
Insights

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

Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Dec 2023
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (29) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $163,742 in federal fines (most recent 2023-12-13)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (59%) 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 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 3 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
105 Eastside Dr · (502) 868-0664 · Call to confirm hours
Pharmacy
705 S Broadway St · (502) 863-9823 · Call to confirm hours
Grocery
Kroger1.5 mi
100 S Broadway St · (502) 867-4994 · Call to confirm hours
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 3 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 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 held steady at 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 increased10.5%13.8%15.4%better
Long-stay residents who lose too much weight7.9%6.6%5.4%worse
Long-stay residents with a catheter left in their bladder0.0%0.5%0.9%better
Long-stay residents with a urinary tract infection0.0%1.6%2.0%better
Long-stay residents with depressive symptoms15.2%17.7%6.5%better 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 injury2.4%3.9%3.3%better
Long-stay residents whose ability to walk worsened19.2%14.0%16.1%worse
Long-stay residents on antianxiety or hypnotic medication33.3%29.8%18.9%worse
Long-stay residents given the seasonal flu vaccine85.3%96.2%95.3%worse
Long-stay residents with pressure ulcers5.9%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control24.1%19.0%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table17.3%16.1%17.1%typical
Short-stay residents who newly got an antipsychotic medication3.1%1.7%1.4%worse
Short-stay residents given the seasonal flu vaccine76.3%83.5%79.4%typical
Long-stay hospitalizations per 1,000 resident days0.631.941.67better
Long-stay outpatient ER visits per 1,000 resident days0.962.141.80better

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.

41.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 31 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

41.2%U.S. median 51.5%
Got home and stayed home
11.3%U.S. median 10.7%
Went back to hospital
35.0%U.S. median 56.6%
Met the expected recovery
0.21U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.05hours / resident / day
Occupational therapy
0.07hours / resident / day
Speech therapy

Met the expected recovery: 35.0% 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 20 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 0.21 therapist hours per resident per day in 2026Q1 — more than 24% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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 SNF41.2%CMS range 27.9–55.851.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.3%CMS range 8.1–17.210.7%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 discharge35.0%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 discharge30.0%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 discharge30.0%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 identified95.8%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 settingnot 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 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 worsened12.5%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 hospitalization9.1%CMS range 5.5–14.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.191.02Oct 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

0.62
RN hours/ resident / day
0.81
LPN hours/ resident / day
2.61
Aide hours/ resident / day
4.04
Total nurse hours/ resident / day
0.50
RN hoursweekends
58.6%
Total nursing turnover
60.0%
RN turnover

How full it usually is: this home is certified for 85 beds and averages 78.5 residents a day — about 92% occupied, or roughly 6 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 4.04 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.62 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.61 is at or above 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 3.66 hrs/resident/day on weekends vs 4.20 on weekdays — 13% thinner on weekends. RN hours go from 0.66 to 0.50 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 59% is well above the national median of 45%.

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

4
deficiencies at the latest standard inspection (2026-03-19)
2
at the previous standard inspection (2024-12-13)

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.

29 citations, most serious first. The 11 most serious are shown; the remaining 18 are one tap away and print in full.

  • Actual harm · G2023-12-13 · 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

    Based on interviews, record reviews, and facility policy review, it was determined the facility failed to protect 9 of 15 sampled residents from abuse and neglect. Specifically, the facility failed to protect Residents #79, #5, #63, #18, and #48 from staff-to-resident verbal and/or physical abuse and Resident #21 from staff neglect. In addition, the facility and failed to protect Residents #63, #34, #49, and #231 from resident-to-resident physical and/or verbal abuse. The findings included: Review of the facility's policy titled Resident Protection Plan, dated 09/15/2022, revealed, Our facility does not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends, or other individuals. Further review of the policy revealed, Verbal Abuse - is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe…

    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 · D2026-03-19 · 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 observation, interview, record review, and review of the Resident Assessment Instrument (RAI), the facility failed to ensure an assessment accurately reflected the resident's status for 1 of 18 sampled residents, Resident (R) 52.Review of the admission Minimum Data Set (MDS) assessment, dated 08/18/2025, and review of the quarterly MDS assessment, dated 02/14/2026, revealed the facility failed to identify R52 had an indwelling catheter. The findings include:Review of the Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0, dated 10/2025, revealed the intent of the items in this section is to gather information on the use of bowel and bladder appliances, the use of and response to urinary toileting programs, urinary and bowel training programs, and bowel patterns. Each resident who is incontinent or at risk of developing incontinence should be identified, assessed, and provided with individualized treatment (medications, non-medicinal treatments and/or devices) and services to achieve or maintain as normal elimination function as possible. An indwelling…

    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 · D2026-03-19 · 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 review of the facility's policy, the facility failed to ensure an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 1 of 18 sampled residents, Resident (R) 70. The findings include:Review of the facility's policy titled, Activity Program, effective 08/04/2024, revealed the facility will provide an on-going activities program to support residents in their choice of activities and to meet the interests of and support the physical, mental, and psychosocial wellbeing of each resident. Review of the Long-Term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0, dated 10/2025, revealed the overall care plan should be oriented towards: 1. Assisting the resident in achieving their goals; and 2. Individualized interventions that honor the resident's preferences. Review of R70's admission Record revealed the facility admitted R70 on 07/14/2024 with diagnoses to include Parkinson's disease,…

    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 · D2026-03-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    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 ensure that each resident who needed respiratory care was provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 18 sampled residents, Resident (R) 2.The findings include:In an interview with the Administrator on 03/19/2026 at 10:42 AM, she stated the facility did not have a policy related to oxygen administration for residents.Review of R2's Face Sheet revealed the facility admitted the resident on 11/26/2025 with diagnoses to include acute respiratory failure with hypercapnia, other chronic osteomyelitis right ankle and foot, and type 2 diabetes mellitus with other diabetic ophthalmic complications.Review of R2's quarterly Minimum Data Set [MDS] with an Assessment Reference Date (ARD) of 01/13/2026, revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of 14 out of 15, indicating the resident was cognitively intact.Review of R2's Physician Orders,…

    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 · D2026-03-19 · tag F0730 — isolated
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and review of the facility's documents, the facility failed to ensure nurse aides received a performance review at least once every 12 months for 1 of 4 employee files reviewed, State Registered Nurse Aide (SRNA) 6.The findings include:Review of the facility's policies revealed no documentation of a policy addressing staff performance evaluations.Review of SRNA6's employee file revealed the facility hired the employee on 06/04/2024; however, further review revealed no documentation of a performance evaluation completed within 12 months of the hire date.In an interview with SRNA6 on 03/18/2026 at 5:38 PM, she stated she thinks she had a performance evaluation in August of 2025, however, no documentation of a completed performance evaluation was available upon request.In an interview with the Administrator on 03/18/2026 at 2:50 PM, she stated she was unable to locate a performance evaluation or training records for SRNA6. She stated it could be misfiled, but was unable to produce any documentation.In further interview with the Administrator on 03/19/2026 at 9:12 AM,…

    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 · Fcited before2024-12-13 · 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, record review, and review of the facility's policy, the facility failed to store food safely in two of two nourishment refrigerators as determined by observations on 12/09/2024, the nourishment refrigerators on the A Unit and the B Unit. The findings include: Review of the facility's policy titled, Food Brought in from Outside Sources and Personal Food Storage, dated 2019, revealed foods from outside sources that required refrigeration or freezing would be labeled with the resident's name and date and stored in the refrigerator/freezer. Per the policy, staff would monitor and document the unit refrigerator temperatures. 1. Observation of the B Unit nourishment refrigerator on 12/09/2024 at 1:42 PM revealed an opened container of applesauce and an opened pudding cup in the door of the refrigerator. Further observation revealed grapes and a container of Chinese food was not dated and not labeled. Also observed in the freezer door were two boxes of lemon glycerin swab sticks, one one-half cup of ice cream, and 36 popsicles that were not dated 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-13 · tag F0761 — failed to label and store drugs safely — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of the package insert for latanoprost ophthalmic solution, and review of the facility's policy, the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents and were stored properly for one of four medication carts, the B Wing Upper medication cart. 1. Observation on [DATE] of the B Wing Upper medication cart revealed it was unlocked and unattended. The staff member who was working with the cart was not in the area. 2. Observation on [DATE] of the B Wing Upper medication cart revealed it contained an unopened box of latanoprost ophthalmic solution 0.005% (used to treat glaucoma) belonging to Resident (R) 3, which was labeled refrigerate. There was also an opened box of latanoprost 0.005% belonging to R3, and neither the box nor bottle were dated. The findings include: Review of the facility's policy titled Medication Storage in the Facility, dated [DATE], revealed medications and biologicals were stored safely, securely,…

    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 · F2023-12-13 · tag F0575 — widespread
    Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and record review, it was determined the facility failed to post the contact information needed for residents to file concerns with the State Survey Agency (SSA). This deficient practice had the potential to affect eighty-one (81) residents. The findings include: Review of the Resident Council Meeting Minutes covering the timeframe from January 2023 through November 2023 included a list of residents' rights. The resident rights included, The resident has the right to receive information from the agencies acting as client advocates, and be afforded the opportunity to contact these agencies. Observation on 12/09/2023 at 10:08 AM, revealed there was no information on how to contact the SSA to submit grievances was posted in the facility. During an interview on 12/07/2023 at 1:27 PM, Resident #51 stated they had no idea how to contact the SSA to file concerns and had no idea where the number for the SSA was located. During an interview on 12/09/2023 at 10:38 AM, Resident #2 stated they did not know how to contact the SSA and added they had no idea where…

    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 · F2023-12-13 · tag F0585 — failed to handle grievances — widespread
    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 observations, interviews, and facility document and policy review, it was determined the facility failed to act promptly on grievances from individual residents and from the Resident Council related to call light response times, receiving scheduled showers, and food concerns involving nine (9) of thirty (30) sampled residents (Residents #2, #13, #14, #35, #42, #50, #51, #54, and #58) with the potential to affect eighty-one (81) residents. The findings include: Review of the facility's policy titled Grievances, dated 11/28/2017, revealed the facility would make prompt efforts to resolve grievances. It further stated the facility wourl ensure all written grievance decisions would include the date the grievance was received, a summary of the resident grievance, the steps taken to investigate, and a summary of the conclusion. 1. During an observation and interview with Resident #2 on 12/09/2023 at 10:38 AM, the resident stated they had activated their call light at 10:30 AM, per the clock in their room, because they required incontinence care. Resident #2 stated most 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 · Fcited before2023-12-13 · 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 observations, interviews, and facility document and policy review, it was determined the facility failed to label and date food items in the reach-in and walk-in coolers; failed to ensure stored cookware was free of food particles and debris; failed to ensure staff maintained the appropriate parts per million (ppm) of available sanitizer for dishes; and failed to ensure staff utilized proper hand hygiene practices and the appropriate use of gloves to prevent food contamination. This deficient practice had the potential to affect 81 residents. The findings included: 1. Review of the facility's policy titled Food Safety and Sanitation, dated 2019, revealed, All time and temperature control for safety (TCS) foods (including leftovers) should be labeled, covered, and dated when stored. Observation of the kitchen on 12/04/2023 at 8:44 AM, accompanied by the Dietary Manager (DM), revealed the following items were in the kitchen: - A container of leftover ribs in the walk-in cooler with no date or label; - A fruit cup in the reach-in cooler with no date; - 25 cups of dessert in…

    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 · E2023-12-13 · tag F0609 — failed to report abuse allegations — pattern
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    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, it was determined the facility failed to report allegations of abuse to the State Survey Agency (SSA) within the mandated timeframes for seven (7) of fifteen (15) residents sampled for allegations of abuse (Residents #184, #79, #5, #63, #48, #34 and #49). The findings include: Review of the facility's policy titled, Resident Protection Plan, dated 09/15/2022, revealed, Any individual observing an incident of abuse or suspecting abuse must immediately report such incident to the Administrator or Director of Nursing Services. Further review of the policy revealed, Should a suspected violation or substantial incident or mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse) be reported, the facility's Administrator, or his/her designee will promptly notify the following persons or agencies (verbally and written) of such incident: a. The state licensing/certification agency responsible for surveying/licensing the facility. The policy indicated, 3. All alleged violations…

    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 18 citations
  • Potential for harm · E2023-12-13 · 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 observations, record reviews, interviews, review of facility policies, and review of the Centers for Disease Control and Prevention (CDC) article titled Injection Safety, Infection Prevention during Blood Glucose Monitoring and Insulin Administration, the facility failed to ensure staff performed proper hand hygiene practices and disinfected contaminated scissors during wound care for one (1) of four (4) sampled residents reviewed for pressure ulcers (Resident #21). In addition, the facility failed to ensure staff donned appropriate personal protective equipment (PPE) when interacting with one (1) of four (4) sampled residents reviewed for transmission-based precautions (Resident #76). The facility failed to ensure nursing staff wore gloves while conducting a finger stick blood glucose test and while administering an insulin injection to one (1) (Resident #51) of two (2) residents observed for finger stick blood glucose testing and insulin injections. The findings included: 1. A review of Resident #21'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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-13 · 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 observations, interviews, record review, and facility document and policy review, the facility failed to promote the dignity for two (2) of thirty (30) sampled residents (Resident #2 and Resident #48). The findings include: Review of the facility's policy titled, Dignity H5MAPL1201, dated 08/01/2013, revealed, each resident would be cared for in a manner that promoted and enhanced quality of life, dignity, respect and individuality. Further review revealed, demeaning practices and standards of care that compromise dignity were prohibited. The policy stated staff would promote dignity and assist residents as needed by, b). Promptly responding to the resident's request for toileting assistance. The Administrator reported on 12/10/2023 at 12:02 PM that the facility had no policy specifically related to call lights or answering call lights. 1. A review of Resident #48's admission Record revealed the facility admitted the resident on 08/03/2023. According to the admission Record, the resident had a medical history that included diagnoses of conversion disorder with seizures 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 · D2023-12-13 · tag F0554 — isolated
    Allow residents to self-administer drugs if determined clinically appropriate.
    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, it was determined the facility failed to ensure one (1) of six (6) residents, observed during medication administration, was prohibited from maintaining their albuterol sulfate inhaler in their possession for self-administration, despite a physician's order indicating the resident was not capable of medication self-administration and without evidence of an assessment to determine if the resident was clinically appropriate for medication self-administration (Resident #23). The findings include: Review of the facility's policy titled, Medication/Self-Administration, undated, revealed, 1. An evaluation should be completed annually or with a change in the resident's condition. 2. The evaluation should be reviewed quarterly with a progress note indicating said review. Attached to the policy was a blank Evaluation of Resident's Ability to Safely Self-Administer Medication, which was a check-off list for the resident to demonstrate knowledge and ability related to self-administration of a medication, along…

    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 · D2023-12-13 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the 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, it was determined the facility failed to notify the resident's responsible party when there was a change of condition for one (1) of one (1) sampled residents reviewed for behavioral health when the resident reported suicidal thoughts (Resident #80). The findings include: Review of the facility's policy titled, Resident Suicide Threats, dated 01/10/2003, revealed It is the policy of this facility that a resident suicide threat be taken seriously and immediately reported to the nurse supervisor and/or charge nurse. The policy revealed, 4. The nurse supervisor/charge nurse will notify the resident's responsible party and the Director of Nursing [DON] of the incident. Review of Resident #180's admission Record revealed the facility admitted the resident on 01/13/2023, with diagnoses that included Alzheimer's disease and anxiety disorder. The admission Record revealed the resident had a medical history that included diagnoses of depression and hallucinations. Further review of the admission Record revealed, Power 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-13 · tag F0582 — isolated
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    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 provide an Advance Beneficiary Notice (ABN) for two (2) of three (3) sampled residents reviewed for Beneficiary Notices (Residents #18 and #31). The findings include: During an interview on 12/10/2023 at 12:37 PM, the Administrator stated the facility did not have a policy for Beneficiary Notices. 1. Review of a Beneficiary Notice-Residents discharged within the Last Six Months worksheet revealed the facility discharged Resident #18 on 10/28/2023 from Medicare covered Part A stay with benefit days remaining. Per the worksheet, the resident remained in the facility to receive further services/care. Review of a Notice of Medicare Non-Coverage (NOMNC) revealed that services for Resident #18 would end on 10/27/2023. Further review revealed Resident #18 was provided the NOMNC notice, which was signed on 10/25/2023. Review of Resident #18's Electronic Medical Record (EMR) revealed no ABN notice was provided to the resident. 2. Review of a Beneficiary Notice- Resident discharged within the Last Six Months…

    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 · D2023-12-13 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interviews, and facility policy review, the facility failed to ensure allegations of abuse were investigated to ensure residents were protected from further abuse for three (3) (Residents #184, #34, and #49) of fifteen (15) residents sampled for allegations of abuse. The findings included: Review of a facility policy titled, Resident Protection Plan, dated 09/15/2022, revealed, All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. 1. A review of Resident #184's admission Record revealed the facility admitted the resident on 08/03/2023 with diagnoses that included bipolar disorder, depression, and anxiety. A review of an admission Minimum Data Set (MDS), with an Assessment Reference Date of 08/06/2023, revealed Resident #184 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident was moderately cognitively impaired. Further review of the MDS revealed the resident had no delirium, psychosis, or behavioral symptoms. A review of Resident #184'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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-13 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    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 interviews, record review, and facility policy review, it was determined the facility failed to notify the resident and/or the resident's representative in writing of a transfer to the hospital and provide a copy of the written notice to the long-term care ombudsman for one (1) (Resident #16) of one (1) sampled resident reviewed for hospitalization. The findings included: Review of an undated facility policy titled, Notice of a Transfer and/or Discharge, did not reveal evidence to specify what information should be provided to the resident and/or their representative when a resident transferred to the hospital. The Notice of a Transfer and/or Discharge policy also did not reference notification of the long-term care ombudsman when a resident transferred to the hospital. Review of Resident #16's admission Record revealed the facility admitted the resident on 02/23/2022. Review of Resident #16's Progress Notes dated 11/23/2023 at 9:08 AM, revealed Resident #16 was transferred to the hospital by way 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-13 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    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 interviews, record review, and facility policy review, it was determined the facility failed to provide written information regarding the facility's bed-hold policy to a resident and/or their representative when the resident transferred to the hospital for one (1) of one (1) sampled resident reviewed for hospitalization (Resident #16). The findings included: Review of an undated facility policy titled, Bed Hold Policy, revealed Our facility shall inform residents upon admission and prior to a transfer for hospitalization or therapeutic leave of our bed-hold policy. The policy specified, 2. When emergency transfers are necessary, the facility will provide the resident or representative (sponsor) with information concerning our bed-hold policy within 24 hours of such transfer. Per the policy, 8. A copy of the resident's bed-hold or release record will be filed in the resident's medical record. Review of Resident #16's admission Record revealed the facility admitted the resident on 02/23/2022. Review 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-13 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and review of the Resident Assessment Instrument (RAI) 3.0, it was determined the facility failed to complete an admission assessment timely for one (1) of twenty-three (23) sampled residents reviewed for Minimum Data Set (MDS) assessments (Resident #234). The findings include: Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, dated October 2023, revealed, The admission assessment is a comprehensive assessment for a new resident and, under some circumstances, a returning resident that must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 if: this is the resident's first time in the facility, OR the resident has been admitted to this facility and was discharged return not anticipated, OR the resident has been admitted to this facility and was discharged return anticipated and did not return within 30 days of discharge. Review of Resident #234's admission Record revealed the facility admitted the resident on 11/10/2023 with diagnoses that included…

    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 · D2023-12-13 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and review of the Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual, it was determined the facility failed to complete a significant change in status Minimum Data Set (MDS) assessment within the required timeframe for one (1) of one (1) sampled residents reviewed for hospice and end of life care (Resident #13). The findings include: Review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, revealed, The SCSA [significant change in status assessment] is a comprehensive assessment for a resident that must be completed when the IDT [interdisciplinary team] has determined that a resident meets the significant change guidelines for either major improvement or decline. Further review revealed, An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program or changes hospice providers and remains a resident at the nursing home. The ARD [Assessment Reference Date] must be within 14 days from the effective date of the hospice…

    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 · D2023-12-13 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    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 interviews, record review and facility policy review, it was determined the facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASRR) was conducted for two (2) of three (3) sampled residents reviewed for PASRR (Resident #55 and Resident #54). Specifically, the facility failed to refer Resident #55 and Resident #54 for a Level II PASRR when the resident was newly diagnosed with a mental illness. The findings included: Review of a document titled 907 [NAME] [Kentucky Administrative Regulations] 1:755. Preadmission Screening and Resident Review Program, effective 08/02/2019, indicated, If a significant change in the individual's condition occurs, the NF [nursing facility] shall complete a significant change request in the department approved system within fourteen (14) calendar days and the appropriate entity shall complete the Level II [Preadmission Screening and Resident Review] PASRR evaluation within nine (9) business days. During an interview on 12/07/2023 at 4:25 PM,…

    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 · D2023-12-13 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, it was determined the facility failed to develop and implement comprehensive care plans to address specific areas for four (4) (Residents #180, #48, #17, and #231) of thirty (30) sampled residents. The findings include: Review of an undated facility policy titled, Care Plans - Comprehensive H5MAPL0110, revealed 1. Our facility's Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for reach resident that identifies the highest level of functioning the resident may be expected to attain. 2. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS [Minimum Data Set]. Each resident's comprehensive care plan is designed to: d. Incorporate identified problem areas; e. Incorporate risk factors associated with identified problems; f. Build on the resident's strengths; g. Reflect…

    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 · D2023-12-13 · 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 interviews, record review, and facility policy review, it was determined the facility failed to revise the care plan for one (1) of fifteen (15) sampled residents reviewed for abuse (Resident #63). The findings include: A review of the facility's policy titled Care Plans - Comprehensive H5MAPL0110, dated September 2022, revealed, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological, cultural and trauma-informed needs is developed for each resident. Further review of the policy revealed, 2. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change [sic]. 3. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: d. When there has been a significant change in the resident's condition; e. When the desired outcome is not met; f. When the resident has been readmitted to the facility from a hospital stay; and g. At least quarterly. Review of Resident #63'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
  • Potential for harm · D2023-12-13 · 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 observations, interviews, record reviews, and facility policy review, it was determined the facility failed to provide showers as scheduled and failed to provide incontinence care for three (3) of seven (7) sampled residents (Resident #48, Resident #2, and Resident #17) reviewed for activities of daily living (ADLs). The findings included: The facility provided pages from the Lippincott Nursing Procedures book with a copyright date of 2023 as their policy and procedures for incontinence care. Review of page 428 revealed, Check the patient's incontinence pad (if applicable) at least every 2 hours to ensure that it's dry. Because the skin lying on an under pad is commonly moist, expose this area to air when turning the patient to allow moisture to evaporate and the skin surface to dry. Regularly and promptly remove soil and irritants from the skin to help prevent or minimize exposure of the skin to damaging irritants. 1. Review of Resident #48's admission Record revealed the facility admitted the resident on 08/03/2023. According to the admission Record, the resident had 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-12-13 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    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 follow Physician's Orders to obtain laboratory values for two (2) of five (5) sampled residents (Resident #4 and Resident #51) reviewed for unnecessary medications. The findings include: Review of the facility's policy titled Medication Monitoring and Management dated 11/2021, revealed The resident's medication regimen is evaluated when one or more of the following occur. An irregularity identified in the pharmacist's monthly medication regimen review (MRR). 1. Review of the admission Record revealed the facility admitted Resident #4 on 06/04/2022 with diagnoses that included hyperlipidemia (high cholesterol), atherosclerotic heart disease, and heart failure. Review of Resident #4's care plan, initiated 08/17/2020, revealed the resident was at risk for malnutrition/dehydration related to hypertension, diabetes, heart disease, and heart failure. Interventions included directions for staff to obtain…

    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 · D2023-12-13 · 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 observations, interviews, record review, and facility policy review, it was determined the facility failed to secure an indwelling urinary catheter to prevent trauma or accidental removal for one (1) of three (3) sampled residents (Resident #48) reviewed for urinary catheters. The findings included: Review of an undated facility policy titled Catheter Associated Urinary Tract Infection (CAUTI) Prevention, revealed, Purpose: To ensure appropriate technique in the care and maintenance of Foley catheters. Further review revealed, Secure catheter properly to prevent movement. A leg strap or tape may be used. Review of Resident #48's admission Record revealed the facility admitted the resident on 08/03/2023. According to the admission Record, the resident had a medical history that included diagnoses of bladder neck obstruction, calculus (stones) in the bladder, benign prostatic hyperplasia with lower urinary tract symptoms, and feeling of incomplete bladder emptying. Review of Resident #48's significant change in status Minimum Data Set (MDS), with an Assessment Reference Date…

    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 · D2023-12-13 · tag F0740 — failed to provide behavioral / mental-health care — isolated
    Ensure each resident must receive and the facility must provide necessary behavioral health care and 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 facility policy review, it was determined the facility failed to provide sufficient psychosocial monitoring for one (1) (Resident #180) of one (1) sampled resident reviewed for behavioral health. Specifically, the facility failed to properly document every fifteen (15)-minute monitoring of the resident after a suicide watch was initiated when the resident verbalized the desire for suicide. The findings included: Review of the facility's policy titled Resident Suicide Threats, dated 01/10/2003, revealed, 1. Resident threats of suicide must be reported immediately to the nurse supervisor/charge nurse. 2. A staff member is to remain with the resident until the nurse supervisor/charge nurse arrives to assess the resident. The facility will implement suicide monitoring and document at least every fifteen (15) minutes. Monitoring will continue until the physician orders otherwise. 3. The nurse supervisor/charge nurse will notify the resident's attending physician and report her…

    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 · D2023-12-13 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review, interview, and facility policy review, it was determined the facility failed to ensure the medication error rate was not 5% or greater. There were two (2) errors out of twenty-eight (28) opportunities observed for two (2) of six (6) residents (Resident #56 and Resident #23) observed during medication administration, which resulted in a medication error rate of 7.14%. The findings included: Review of an undated facility policy titled, Medication Administration General Guidelines for the Administration of Medications, revealed, 3. The nurse or certified medication aide reviews each resident's Medication Administration Record to determine which medications need to be administered at the given time. The nurse observes the five rights in administering each medication: a. The right resident b. The right time c. The right medication d. The right dose e. The right method of administration. 1. A review of Resident #56's Order Summary Report, with active orders as of 12/10/2023, revealed an order dated 03/28/2022 for 81 milligrams (mg) of oral aspirin…

    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

“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

$163,742 in federal fines across 1 penalty.

  • $163,742 — penalty dated 2023-12-13

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.

Part of a chain

This home belongs to BLUEGRASS HEALTH KY — 15 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 53.1-2.1 vs chain
Health inspection 2 of 53.4-1.4 vs chain
Staffing 1 of 51.6-0.6 vs chain
Quality measures 3 of 53.5-0.5 vs chain
The other 14 homes this chain runs (chain average 3.1★, 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
DOVER MANOR OPERATIONS HOLDINGS LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/01/2023
FISCHEL, MAYERIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF33%since 01/01/2023
GRINSPAN, ELIIndividual5% OR GREATER INDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF33%since 01/01/2023
HUNTINGTON BANKOrganization5% OR GREATER MORTGAGE INTERESTsince 01/01/2023
VALLEY STREAM OPERATOR I LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2023
RAYBURN, NATASHAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/31/2023
FARKOVITS, JOSHUAIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 06/30/2025
DOVER MANOR REALTY HOLDINGS LLCOrganizationADP OF THE SNFsince 01/01/2023
DOVER MANOR REALTY LLCOrganizationADP OF THE SNFsince 01/01/2023
ALVARADO, RALPHIndividualADP OF THE SNFsince 06/01/2023
BAKER, SHANNONIndividualADP OF THE SNFsince 04/01/2024

CMS files one row per role, so the 17 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.

5 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
-2.4%
Operating marginrevenue minus expenses
$879K
Related-party expense9% of expenses
Who pays — share of resident-days
Medicaid 75%Medicare 7%Other / private 18%

About 75% 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 $879K 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

$323per resident / day
operating cost
$9,811per month
≈ monthly operating cost
$315per 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 185295. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-19, 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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