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Bradford Heights Nursing & Rehabilitation

950 Highpoint Drive, Hopkinsville, KY 42240 · For profit - Limited Liability company · 100 certified beds · (270) 885-1151 Medicare & Medicaid certified

Call the home — (270) 885-1151 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

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

In its favor
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (22) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (57%) runs well above the national median (45%)
  • about 31% of its spending goes to commonly-owned related companies

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 2 of 5

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1411 W 7th St · (270) 885-7337 · Call to confirm hours
Pharmacy
1112 W 7th St · (270) 886-4466 · Call to confirm hours
Grocery
Pantry1.5 mi
932 N Main St · (270) 885-5231 · Call to confirm hours
Park
Ruff Park0.8 mi
Litchfield Dr · (270) 887-4290 · Typically dawn to dusk
Place of worship
208 Sanderson Dr

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

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 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 improved from 1 to 2 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 rating2★
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 increased19.0%13.8%15.4%worse
Long-stay residents who lose too much weight9.2%6.6%5.4%worse
Long-stay residents with a catheter left in their bladder0.2%0.5%0.9%better
Long-stay residents with a urinary tract infection0.9%1.6%2.0%better
Long-stay residents with depressive symptoms0.0%17.7%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.2%0.1%better
Long-stay residents with falls causing major injury3.4%3.9%3.3%typical
Long-stay residents whose ability to walk worsened17.1%14.0%16.1%typical
Long-stay residents on antianxiety or hypnotic medication21.9%29.8%18.9%worse
Long-stay residents given the seasonal flu vaccine64.8%96.2%95.3%worse
Long-stay residents with pressure ulcers6.2%4.8%4.7%worse
Long-stay residents with worsening bladder/bowel control19.1%19.0%21.2%better
Long-stay residents who got an antipsychotic medication — see the note below the table4.9%16.1%17.1%better
Short-stay residents who newly got an antipsychotic medication1.4%1.7%1.4%typical
Short-stay residents given the seasonal flu vaccine9.5%83.5%79.4%worse
Short-stay residents rehospitalized after admission30.6%24.2%22.6%worse
Short-stay residents with an outpatient ER visit11.7%13.7%12.0%typical
Long-stay hospitalizations per 1,000 resident days0.961.941.67better
Long-stay outpatient ER visits per 1,000 resident days1.892.141.80typical

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

§ 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.

45.0% 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 160 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

45.0%U.S. median 51.5%
Got home and stayed home
14.1%U.S. median 10.7%
Went back to hospital
38.8%U.S. median 56.6%
Met the expected recovery
0.30U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 38.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 49 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 0.30 therapist hours per resident per day in 2026Q1 — more than 48% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 7% 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 SNF45.0%CMS range 37.2–54.251.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF14.1%CMS range 10.8–17.210.7%Oct 2022–Sep 2024worse than U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge38.8%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge44.9%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 discharge30.6%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 identified2.3%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 setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge93.5%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay2.3%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 worsened8.1%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 hospitalization8.0%CMS range 4.7–13.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.011.02Oct 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

0.36
RN hours/ resident / day
0.73
LPN hours/ resident / day
2.09
Aide hours/ resident / day
3.18
Total nurse hours/ resident / day
0.19
RN hoursweekends
57.1%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 100 beds and averages 91.5 residents a day — about 92% occupied, or roughly 8 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 3.18 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.36 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.09 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 2.80 hrs/resident/day on weekends vs 3.33 on weekdays — 16% thinner on weekends. RN hours go from 0.42 to 0.19 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 57% 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

2
deficiencies at the latest standard inspection (2025-09-12)
7
at the previous standard inspection (2024-09-20)

Deficiencies are fewer than at the previous inspection — improving. 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.

22 citations, most serious first. The 10 most serious are shown; the remaining 12 are one tap away and print in full.

  • Potential for harm · D2026-05-29 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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 Observation, interview, and facility policy review revealed the facility failed to maintain a homelike environment for residents related to peeling paint on the walls in room [ROOM NUMBER], holes in the wall in rooms [ROOM NUMBER], and stained ceiling tiles in rooms 100, 107, 109, and 119. This affected four (4) out of 20 sampled residents, R11, R12, R19, and R20.The findings include: Review of the facility's policy, titled, Resident Rights Policy, reviewed 04/2026, revealed residents had a right to a safe, clean, comfortable, and homelike environment.Request for the facility's maintenance policy revealed that they didn't have any policies pertaining to maintenance of their building.Observation of room [ROOM NUMBER] on 05/26/2026 at 4:00 PM revealed three (3) stained ceiling tiles in the left corner of the room and above the window. The fabric window covering was also stained. The tiles were yellowish-brown from apparent moisture.Observation of room [ROOM NUMBER] on 05/26/2026 at 4:03 PM revealed staining on two…

    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 · Dcited before2026-05-29 · 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

    Observation, interview, and review of facility policies revealed the facility failed to provide assistance with incontinence care in a timely manner for four (4) of 10 sampled residents (R1, R6, R7, and R14).The findings include: Review of the facility's policy titled, Resident Rights Policy, reviewed 04/2026, revealed residents had the right to receive services in the facility with reasonable accommodation of the resident's needs and preferences.Review of the facility's policy titled, Activities of Daily Living Policy, revised 04/2026, revealed residents who were unable to carry out activities of daily living would receive the necessary services to maintain good personal hygiene.Review of the facility's policy titled, Perineal Care Policy, reviewed 04/2026, revealed it was the practice of the facility to provide perineal care to all incontinent residents as needed in order to promote cleanliness and comfort, as well as to prevent infection and skin breakdown.Observation of the 300 hall on 05/27/2026 at 9:38 AM revealed Resident (R)6's call light engaged. His room smelled of feces…

    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 · D2026-05-29 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and review of the facility policies, the facility failed to ensure pain assessments were completed prior to and after the administration of as needed (PRN) narcotic pain medications for four (4) out of four (4) sampled residents, Resident (R)4, R8, R16, and R18.The findings include: Review of the facility's policy, titled, Pain Management Policy, revised 04/2026, revealed the facility would utilize a systematic approach for recognition, assessment, treatment, and monitoring of pain. It further revealed, the facility would use a pain assessment tool, appropriate for the resident's cognitive status, to assist staff in consistent assessment of a resident's pain. The policy stated, Facility staff will reassess resident's pain management at established intervals for effectiveness and / or adverse consequences.Review of the facility's policy, titled, PRN Medication Policy, reviewed 04/2026, revealed documentation would be provided in the resident's medical record to show adequate indications for a medication's use. Further, the policy advised that, when…

    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 before2026-04-10 · 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

    Based on observation, interview, record review, and facility policy review, the facility failed to ensure that medications with expired or post discard dates were not available for resident use for one of four sampled residents (Resident (R) 1). Observation on 04/08/2026 revealed an intravenous (IV) antibiotic (Meropenem) container hanging on an IV pole in R1's room labeled with directions to discard the medication after 03/03/2026.The findings include: Review of the facility's policy titled, Medication Storage last revision date of 02/01/2026, revealed A. Expiration dates (beyond-use date) of dispensed medications shall be determined by the pharmacist at the time of dispensing. B. Drugs dispensed in the manufacturer's original container will be labeled with the manufacturer's expiration date. The policy failed to include directions for staff on how to appropriately address medications past their discard date. Review of R1's Resident Face Sheet found in facility's electronic medical record revealed the facility admitted the resident on 03/23/2026 with diagnoses of acute…

    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 · Dcited before2026-04-10 · 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, and facility policy review, the facility failed to ensure all staff properly adhered to infection control and personal protective equipment (PPE) regulations in accordance with professional standards for one of four sampled residents (Resident (R) 1) for enhanced barrier isolation. Observation on 04/08/2026 revealed a staff member entered a R1's room, who was on enhanced barrier precautions and performed direct resident care without donning the appropriate PPE. The findings include: Review of facility's policy titled, Infection Prevention and Control Program, last revision date 01/20/2026, revealed the facility had established and maintained 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. Further review of the policy revealed 16. Staff Education: A. All staff shall receive training, relevant to their specific roles and responsibilities, regarding the facility's infection prevention…

    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 · Dcited before2025-09-12 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of the facility's policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, which had the potential to affect 93 of the facility's 93 residents who consumed food from the kitchen. The findings include: Review of the facility policy titled, Food Storage, revised 10/2019, revealed the Dining Service Director/Cook(s) were to ensure all food items were stored properly in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Observation on 09/09/2025 at 10:15 AM, with the Dietary Manager (DM) revealed her hairnet receded approximately three inches above the hairline exposing uncovered hair on both sides of her head above her ears and in the front above her forehead. Continued observation of the kitchen, of refrigerator, 1 revealed a container of strawberries covered with mold. Observation revealed two heads of lettuce stored in a plastic bag that was opened, uncovered, and undated. Observation of freezer 1 revealed a box…

    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 · Dcited before2025-09-12 · 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, and facility policy review, 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 2 of 3 residents sampled for wound care out of the total sample of 20, (Resident (R)2 and R6). The findings include: Review of the facility's policy titled, Infection Prevention and Control Program, revised on 02/02/2025, revealed it was the facility's policy for hand hygiene to be performed in accordance with the facility's established hand hygiene procedures. Review of the facility's policy titled, Wound Care-Dressing Change, reviewed 03/24/2025, revealed it was the facility's policy to clean the bedside table with facility approved cleaning wipes and use a clean barrier to establish a clean field on resident's overbed table for placement of (wound care) supplies. Continued review of the policy revealed staff providing wound care were to remove their gloves…

    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 · Fcited before2024-09-20 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of the facility's policy, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, which had the potential to affect 90 of the facility's 94 residents who consumed food from the kitchen. Observation during the initial kitchen tour revealed numerous food items in the reach-in cooler not labeled or dated. In addition, continued observation of the kitchen revealed [NAME] 2 failed to have a beard covering in place. Further observation revealed [NAME] 2 failed to utilize utensils when serving food, using his gloved hands and not changing gloves. The findings include: Review of the facility's policy titled, Food Preparation and Service, undated, revealed, Culinary service employees shall prepare and serve food in a manner that complies with safe food handling practices. Per policy review, food preparation staff were to adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Continued review revealed bare hand contact with food was…

    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 · D2024-09-20 · tag F0561 — failed to honor residents' choices — isolated
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    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 ensure each resident had the right to choose activities, schedules, health care and providers of health care services consistent with his or her interests, assessments, and plan of care and the resident had a right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 30 sampled residents (Resident #6 (R6)). The findings include: Review of the facility's policy titled, Resident Self Determination and Participation, dated 02/22/2024, revealed the facility was to promote and facilitate a resident's right to self-determination through support of the resident's choice. Further review revealed a resident had the right to make choices about aspects of his or her life that were significant to the resident. Review of R6's Face Sheet for revealed the facility admitted the resident on 05/06/2016, with diagnoses that included chronic obstructive pulmonary disease (COPD), anxiety disorder, and morbid obesity (severe), due to excess…

    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 · D2024-09-20 · tag F0585 — failed to handle grievances — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policy, the facility failed to ensure its grievance policy was followed to ensure prompt resolution of all residents' grievances and completion of such grievances for 2 of 30 sampled residents (Residents (R6 and R73)). The findings include: Review of the facility's policy titled, Resident and Family Grievances, revised 03/14/2024, revealed the facility was to support each resident's and family member's right to voice grievances without fear of discrimination or reprisal. The policy stated the (facility's) grievance official was responsible for overseeing the grievance process; receiving and tracking grievances through to the conclusion. Continued review revealed the staff member receiving a grievance was to record the nature and specifics of the grievance on the designated grievance form and forward the form to the grievance official as soon as practicable. Per policy review, the written decision was to include, at a minimum: the date the grievance…

    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
Show the remaining 12 citations
  • Potential for harm · D2024-09-20 · tag F0645 — isolated
    PASARR screening for Mental disorders or Intellectual Disabilities
    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, the facility failed to ensure residents received a Level II Preadmission Screening and Resident Review (PASRR) referral based on the positive Level 1 PASRR screening results for 1 of 2 residents sampled for Level II PASRR out of the total sample of 30 residents (Resident #23 (R23)). The facility assessed R23 to have a positive Level I PASRR screen on admission on [DATE], related to her diagnoses and psychiatric (psych) stay. Based on the positive Level I PASRR, R23 required a Level II Screening related to diagnoses of schizophrenia and bipolar disorder. However, the facility failed to ensure R23 received a Level II PASRR evaluation as required. The findings include: Review of the facility's policy, Resident Assessment-Coordination with PASRR Program, revised 03/14/2023, revealed, the facility coordinated assessment with the Pre admission Screening and Resident Review (PASRR) program under Medicaid. Per policy review, the PASRR assessment was…

    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 · Dcited before2024-09-20 · 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 observation, interview, record review and review of facility polity, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs as identified in the comprehensive assessment for 2 of 30 sampled residents (Resident (R)23 and R99). 1. The facility admitted R99 on 04/28/2022, and on 05/04/2024 assessed R99 as being at risk for developing pressure injuries. However the facility failed to develop a care plan for at risk for impaired skin integrity or risk for developing pressure injuries. On 05/11/2024, R99 developed a suspected deep tissue injury (SDTI) to the right heel. 2. The facility admitted R23 with diagnoses of schizophrenia, bipolar disorder, depression, and anxiety. However, the facility failed to develop and implement a care plan to address R23's psychiatric diagnoses. The findings include: Review of the facility's policy titled,…

    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 · D2024-09-20 · 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

    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 ensure interventions were in place to prevent a resident from developing a pressure injury for 1 of 30 sampled residents, (Resident (R)99). On 05/11/2022, 13 days following admission to the facility, Resident 99 developed a facility acquired suspected deep tissue injury (SDTI) to the right heel. The findings include: Review of the facility's policy titled, Pressure Injury, Prevention, and Management, revised 08/30/2022, revealed, the facility was committed to the prevention of avoidable pressure injuries, unless clinically unavoidable . Per policy review, the facility was also committed to providing treatment and services to heal a pressure ulcer/injury, prevent infection and development of additional pressure ulcers/injuries. Continued review revealed after completing a thorough assessment/evaluation, the interdisciplinary team (IDT) was to develop a relevant care plan that included measurable goals…

    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 · D2024-09-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    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 that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 30 sampled residents, (Resident (R)83). R83 experienced significant weight loss; however, the facility failed to notify the Physician of the resident's significant weight loss and failed to follow recommendations from the Registered Dietician (RD). The findings include: Review of the facility's policy titled, Weight Assessment/Monitoring, dated 01/01/2021 and revised 02/20/2024, revealed the multidisciplinary team was to strive to prevent, monitor, and intervene for undesirable weight loss of facility residents. Review of R83's Face Sheet revealed the facility admitted the resident on 11/29/2023, with diagnoses that included acute kidney failure, disorientation, and weakness. Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 08/06/2024, revealed the facility assessed R83 to have a Brief…

    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 before2024-09-20 · 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, and review of facility 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 infections, for 1 of 30 sampled residents, (Resident (R)41). Observation revealed Certified Medication Aide (CMA) 2 administered R41's ophthalmic eye drops without wearing gloves. The findings include: Review of the facility's policy titled, Specific Medication Administration Procedures, dated 05/2022, revealed the purpose of the policy was for administering ophthalmic solution/suspension into the eye in a safe, accurate, and effective manner. Continued review revealed examination gloves were to be utilized to administer the eye drops. Further review revealed the procedure required staff to perform hand hygiene, put on examination gloves, and with a gloved finger gently pull down the lower eyelid to form a pouch while instructing the resident to look up and instill the prescribed number of drops…

    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 · Fcited before2019-11-27 · 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 — the official record, unedited, may be distressing

    Based on observation, interview, and review of the facility's policy, it was determined the facility failed to store food in accordance with professional standards for food service safety. Observation of the kitchen on 11/25/19 revealed a bag of waffles and green peppers stored in the freezer and were not dated. Review of the Census and Condition, dated 11/25/19 revealed ninety-two (92) of ninety-two (92) residents received their meals from the kitchen. The findings include: Review of the facility's policy and procedure titled, Leftovers, not dated, revealed leftovers will be covered, labeled, and dated; (refrigerated or frozen if necessary) immediately after the end of the meal service. Observation on 11/25/19 at 11:21 AM, of the walk-in freezer, revealed one (1) bag of waffles and one (1) bag of green peppers, not dated when placed in the freezer. Interview with the Dietary Manager on 11/25/19 at 11:41 AM, revealed any food or food items should be dated and labeled when placed in the freezer and anything not dated should be discarded.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-11-27 · 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 observation, interview, record review, and facility policy review, it was determined the facility failed to implement a comprehensive person-centered care plan with services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being related to Activities of Daily Living (ADL's) and Catheter Care for two (2) of eighteen (18) sampled residents, (Resident #74 and #189). The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated December 2016, revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. Record review revealed the facility admitted Resident #74 on 07/27/19 with diagnoses of Nodular Prostate with Lower Urinary Tract Symptoms, Chronic Viral Hepatitis, Diabetes Type ll, Vascular Dementia with Behavioral Disturbance, and Hemiplegia…

    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 · Dcited before2019-11-27 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide activities of daily living (ADL's) to one (1) of eighteen (18) sampled resident who wast unable to carry out own ADL's (Resident #74). Observations of Resident #74 during a three day time frame revealed the resident facial hair was unshaven and fingernails on both hands and feet were long, jagged, and not trimmed. In addition, there was a black colored substance underneath fingernails on both hands. The findnigs include: Review of the facility's policies titled, Care of Fingernails/Toenails and Shaving The Resident, dated October 2010, revealed the purposes of the procedure is to promote cleanliness, to provide skin care, and to clean the nail bed, to keep nails trimmed, and to prevent infections. Information of care provided should be recorded in the resident's medical record. Notify the supervisor if the resident refuses the care. Record review revealed the facility admitted Resident #74…

    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 · D2019-11-27 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure a resident, with or without an indwelling catheter, receives the appropriate care and services to prevent urinary tract infections to the extent possible for three (3) of eighteen (18) sampled residents, (Resident #37, #74, and #189). The findings include: Review of the facility's policy titled, Catheter Care, Urinary, not dated, revealed the purpose of this procedure is to prevent catheter-associated urinary tract infections. Infection Control: use standard precautions when handling or maintaining the drainage system. Be sure catheter tubing and drainage bag are kept off the floor. For a male resident: Use washcloth with warm water and soap to cleanse around the meatus. Cleanse the glans using circular strokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Return foreskin 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 · D2019-11-27 · 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, record review and facility policy review, it was determined the facility failed to ensure one (1) of eighteen (18) sampled residents' nebulizer treatments were provided in accordance with professional standards of practice (Resident #46). Observation on 11/26/19 at 3:20 PM revealed Resident #46 was lying in bed yelling out and there was a nebulizer (breathing treatment) mask, empty and running, lying on the resident's chest with the resident pointing at the nebulizer mask, attempting to talk by yelling out. There was no nurse in the room. The findings include: Review of the facility policy titled, Administering Medication through a Small Volume (Handheld) Nebulizer. last revised, October 2010 revealed the purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. Steps in the procedure include .Ask the resident to hold the mouthpiece gently between his/her lips. Instruct the resident to take a deep breath, pause briefly and then exhale normally. Encourage the resident to repeat…

    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 · D2019-11-27 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    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 facility policy review, it was determined the facility failed to ensure one (1) of eighteen (18) sampled residents was not administered a Psychotropic medication without an appropriate diagnosis (Resident #87). Resident #87 was being administered Seroquel (anti-psychotic medication), for the diagnosis of anxiety. The findings included: Review of the facility policy titled, Anti-psychotic Medication Use, last revised December 2016, revealed residents will only receive anti-psychotic medication when necessary to treat specific conditions for when they are indicated and effective. Anti-psychotic medication shall generally be used only for the following conditions/diagnoses as documented in the record consistent with the definition(s) in the Diagnostic and Statistical Manual of Mental Disorders (current or subsequent editions): A. Schizophrenia; B. Schizo-affective disorder; C. Schizophreniaform disorder; D. Delusional disorder; E. Mood disorders (bipolar disorder,…

    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 · Dcited before2019-11-27 · 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, and review of the facility's policy and procedure, it was determined the facility failed to ensure drugs used in the facility are labeled in accordance with currently accepted professional principles. On [DATE], observation of two (2) of two (2) medication carts on the 100 and 200 Hall, revealed medication not dated when opened. The findings include: Review of the facility's policy titled, Labeling of Medication Containers, last revised [DATE], revealed all medications in the facility shall be properly labeled in accordance with current state and federal regulations. Observation of the 100 Hall medication cart #1, on [DATE] at 10:59 AM, revealed one (1) bottle of Novolin R (insulin), opened and not dated. Observation of the 200 Hall medication cart #2, on [DATE] at 11:43 AM, revealed one (1) bottle of Novolin R, opened and not dated. Interview with Kentucky Medication Aide (KMA) #1, on [DATE] at 2:45 PM, revealed all insulin's should be dated when opened because they have an…

    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

No federal fines in the current CMS record.

Part of a chain

This home belongs to SIMCHA HYMAN & NAFTALI ZANZIPER — 79 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 52.6-1.6 vs chain
Health inspection 2 of 52.7-0.7 vs chain
Staffing 1 of 52.2-1.2 vs chain
Quality measures 2 of 53.4-1.4 vs chain
The other 78 homes this chain runs (chain average 2.6★, per CMS)
1 of 5Beavercreek Health And RehabBeavercreek, OH 1 of 5Centerville Health And RehabDayton, OH 1 of 5Clayton Rehabilitation and Healthcare CenterClayton, NC 1 of 5Dade City Health And Rehabilitation CenterDade City, FL 1 of 5Englewood Health And RehabEnglewood, OH 1 of 5Fulton Nursing and Rehabilitation, LLCFulton, KY 1 of 5Gainesville Health and RehabilitationGainesville, FL 1 of 5Garden View Health And Rehabilitation CenterVero Beach, FL 1 of 5Hertford Rehabilitation and Healthcare CenterHertford, NC 1 of 5Longwood Health And Rehabilitation CenterLongwood, FL 1 of 5Lotus Village Center for Nursing and RehabilitatioSparta, NC 1 of 5Magnolia Creek Nursing And RehabilitationCovington, TN 1 of 5Mills Nursing & RehabilitationMayfield, KY 1 of 5Mountain Ridge Health and RehabilitationMonticello, KY 1 of 5Naples Health And Rehabilitation CenterNaples, FL 1 of 5Southpoint Rehabilitation and Healthcare CenterDurham, NC 1 of 5Spring View Nursing & RehabilitationLeitchfield, KY 1 of 5Sunrise Point Health And Rehabilitation CenterRockledge, FL 1 of 5Windsor Rehabilitation and Healthcare CenterWindsor, NC 1 of 5Winter Park Care And RehabilitationWinter Park, FL 1 of 5Xenia Health And RehabXenia, OH 2 of 5Accordius Health at Rose Manor LLCDurham, NC 2 of 5Barren County Nursing and RehabilitationGlasgow, KY 2 of 5Bellbrook Health And RehabBellbrook, OH 2 of 5Cherokee Park RehabilitationLouisville, KY 2 of 5Clinton PlaceClinton, KY 2 of 5Collierville Nursing And Rehabilitation, LlcCollierville, TN 2 of 5Eden Rehabilitation and Healthcare CenterEden, NC 2 of 5Fairpark Health And RehabilitationMaryville, TN 2 of 5Glenview Health and RehabilitationGlasgow, KY 2 of 5Green Acres HealthcareMayfield, KY 2 of 5Jamestown Place Health And RehabJamestown, OH 2 of 5Lilac At Bayview, TheSaint Augustine, FL 2 of 5Madisonville Health and Rehabilitation, LLCMadisonville, KY 2 of 5Midtown Center For Health And RehabilitationMemphis, TN 2 of 5Pelican Health at CharlotteCharlotte, NC 2 of 5River Grove Health And RehabilitationLoudon, TN 2 of 5Stonecreek Health and RehabilitationPaducah, KY 2 of 5Sycamore Heights Health and RehabilitationLouisville, KY 2 of 5Venice Health And Rehabilitation CenterVenice, FL

Showing 40 of 78; lowest-rated first.

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
CLEARVIEW KY SNF HOLDCO LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST100%since 12/01/2021
HOPPER, TIAIndividualW-2 MANAGING EMPLOYEEsince 10/05/2023
VUJANOVIC, MICKIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2020
CLEARVIEW HEALTHCARE MANAGEMENT KY LLCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2020

CMS files one row per role, so the 5 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

$10.1M
Net patient revenuemost recent cost report
+5.2%
Operating marginrevenue minus expenses
$3.0M
Related-party expense31% of expenses
Who pays — share of resident-days
Medicaid 73%Medicare 9%Other / private 18%

About 73% 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 $3.0M paid to related parties — landlords or management companies under common ownership — equal to about 31% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$291per resident / day
operating cost
$8,835per month
≈ monthly operating cost
$307per 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 185076. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-12, 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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