Pine Meadows Post Acute
1608 Hill Rise Drive, Lexington, KY 40504 · For profit - Limited Liability company · 120 certified beds · (859) 254-2402 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high number of inspection citations overall (16) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing rating is low (1/5)
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 1 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 4 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 5.7% | 13.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 7.2% | 6.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.9% | 1.6% | 2.0% | typical |
| Long-stay residents with depressive symptoms | 81.9% | 17.7% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 1.8% | 3.9% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 1.9% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 21.4% | 29.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 93.0% | 96.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.4% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 30.3% | 19.0% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 8.4% | 16.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.7% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 93.4% | 83.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 23.4% | 24.2% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 15.9% | 13.7% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 3.09 | 1.94 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.36 | 2.14 | 1.80 | better |
‡ 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.
48.1% 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 49 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 48.5% 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 66 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 0.32 therapist hours per resident per day in 2026Q1 — more than 53% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 48.1%CMS range 35.5–60.7 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.9%CMS range 7.5–14.2 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 48.5% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 53.0% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 22.7% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS 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 discharge | not 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 stay | 1.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.5%CMS range 4.3–11.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.04 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 120 beds and averages 115.1 residents a day — about 96% occupied, or roughly 5 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.62 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.50 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 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 3.19 hrs/resident/day on weekends vs 3.79 on weekdays — 16% thinner on weekends. RN hours go from 0.57 to 0.30 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 49% is about the same as 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
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.
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.
16 citations, most serious first. The 10 most serious are shown; the remaining 6 are one tap away and print in full.
- Potential for harm · Fcited before2025-09-05 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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, review of a U.S. Food and Drug Administration document, and review of the facility's policies, the facility failed to provide a safe, sanitary environment for food production and storage, which could affect 117 of the 117 current residents that received food from the kitchen.During the initial kitchen tour on 09/02/2025, observations revealed staple food bins unlabeled and undated, other commercial mixes out of the original packaging with no opened date, and personal items, including backpack and jacket, stored in the dry storage room on top of canned and packaged foods. Also, temperatures were missing on the logs for the tray line and for the walk-in refrigerator and freezer. Observation of the kitchen ceiling on 09/03/2025 and 09/04/2025 revealed dripping condensation and peeling gray paint on the ceiling. Observation of one nourishment refrigerator on 09/05/2025 revealed an expired item which had no opened date marked on it, and review of another nourishment refrigerator temperature log revealed the log had the acceptable range for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-05 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility's policies, the facility failed to provide a safe, sanitary, and comfortable environment, and to prevent the onset and transmission of communicable diseases and infections by failing to disinfect 1 of 9 Hoyer lifts observed.The findings include:Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 09/2022, revealed reusable resident care equipment and durable medical equipment (DME) were cleaned and disinfected before reuse by another resident.Review of the facility's policy titled, Policies and Practices - Infection Control, revised 10/2018, revealed the objectives of the facility's infection control policies and practices were to prevent, detect, investigate, and control infections in the facility; and maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.Observation on 09/03/2025 at 3:19 PM revealed Certified Nursing…
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.
- Potential for harm · D2023-11-30 · tag F0644 — isolatedCoordinate 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
Based on interviews, record review, and facility document and policy review, it was determined the facility failed to ensure one (1) of three (3) residents reviewed for Pre-admission Screening and Resident Review (PASARR), (Resident #94) who had a newly evident or possible serious mental disorder was referred to the appropriate state-designated mental health or intellectual disability authority for review. Findings included: A review of the facility policy titled admission Criteria, revised in March 2019, revealed, Our facility admits only residents whose medical and nursing care needs can be met. The policy revealed, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The policy did not address a resident who previously had a negative Level I screening and who was later identified with a newly evident or possibly serious MD, ID, or a related condition. A review of Resident #94's admission Record revealed the facility…
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.
- Potential for harm · Dcited before2023-11-30 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review, and facility policy review, the facility failed to develop an individualized, person-centered activities care plan for one (1) of twenty-three (23) sampled residents (Resident #56). Findings included: A review of a facility policy titled Care Plans, Comprehensive Person-Centered Policy, dated March 2022, revealed, A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychological and functional needs. 1. A comprehensive, person-centered care plan for the resident should be developed by the interdisciplinary team (IDT), with input from the resident, and his/her family or legal representative. The policy further revealed, 6. The comprehensive, person-centered care plan should: a. Include measurable objectives and time frames; b. Describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental, and psychosocial wellbeing that the resident desires or that is possible. A review of Resident #56's admission…
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.
- Potential for harm · D2023-11-30 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review, and facility policy review, it ws determined the facility failed to provide an ongoing program of activities designed to meet the resident's interests for one (1) of twenty-three (23) sampled residents, (Resident #56). Findings included: A review of a facility policy titled Activity Programs revised in August 2006, revealed, Activity programs designed to meet the needs of each resident are available on a daily basis. Policy Interpretation and Implementation 1. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. 2. Residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup, and critique of the programs. 3. Our activity programs consist of individual and small and large group activities that are designed to meet the needs and interest of each resident. A review of Resident #56's admission Record revealed the facility admitted the resident on 05/07/2021. The resident had diagnoses that included cognitive communication deficit,…
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.
- Potential for harm · D2023-11-30 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review, and facility document and policy review, it was determined the facility failed to ensure prompt treatment of a pressure ulcer for one (1) of five (5) residents reviewed for pressure ulcers (Resident #264). Findings included: A review of a facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised in April 2018, revealed, The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. The policy revealed, The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. A review of a document titled [name of medical facility] Medical Partners, dated 05/07/2022 (prior to Resident #264's admission to the facility), revealed a Physical Exam that indicated Resident #264 had a deep tissue injury to the right heel. The document indicated that Resident #264's family member reported the wound had been present…
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.
- Potential for harm · Fcited before2022-08-12 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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, it was determined the facility failed to serve and store food under sanitary conditions. Observations, on 08/08/2022 and 08/09/2022, revealed dry storage with dented cans; no label on a can; ingredient bins with food thickener, lids not closed; vents in dry storage with dust accumulation; vents in kitchen ceiling with dust and dripping water in front of the walk-in refrigerator and walk-in freezer. Further observations, on 08/11/2022, of the nourishment refrigerator on Unit 1, revealed it was not clean on the lower shelf; no identification on a frozen resident meal, and the boxed cookies were not dated. The findings include: Review of the facility's policy titled, Safe Dietary Practices, dated 10/2017, revealed all foods and fluids would be labeled by Dietary with two (2) dates; one (1) for the stock date and one (1) for the use by date, the manufacture's expiration date. The policy stated, if a food or fluid product did not have an expiration date, once it was opened, it must be labeled with a three (3) day…
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.
- Potential for harm · Fcited before2022-08-12 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 13.a. Observation, on 08/09/2022 at 3:58 PM, revealed LPN #1, after performing a blood glucose check on Resident #34, returned to the medication cart and opened the top right drawer. He picked up an alcohol pad and wiped only the end of the glucometer and placed the glucometer back in the drawer. Interview with LPN #1, on 08/09/2022 at 3:59 PM, revealed he cleaned the glucometer after each use with an alcohol pad. b. Observation, on 08/11/2022 at 9:00 AM, revealed LPN #3 sanitized her hands and put on gloves before she cleaned the used glucometer with only one (1) Sani-Cloth. LPN #3 failed to take another disinfecting wipe and wipe the meter thoroughly per the manufacturer's instructions. Interview with LPN #3, on 08/11/2022 at 9:02 AM, revealed she cleaned the glucometer after each use with a Sani-Cloth and then let the glucometer sit for two (2) minutes to dry before using again. c. Observation, on 08/11/2022 at 9:05 AM, revealed LPN #5 cleaned the glucometer, after use, with a Sani-Cloth. LPN #5 then put 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.
- Potential for harm · F2022-08-12 · tag F0886 — failed to test for COVID-19 as required — widespreadPerform COVID19 testing on residents and staff.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of the Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) QSO-20-38-NH Memo, review of the Centers for Disease Control and Prevention (CDC) recommendations and guidelines, review of the Kentucky Department for Public Health's (KDPH) Long-Term Care Facility COVID-19 bi-weekly County Indicator Map, review of the BinaxNOW Covid-19 Ag Card Instructions, and review of the facility's policies, it was determined the facility failed to conduct COVID-19 testing, twice weekly, for unvaccinated staff based on the community's COVID-19 transmission levels and the facility's COVID-19 outbreak status. The facility failed to conduct testing and specimen collection in a manner that was consistent with current standards of practice for conducting COVID-19 tests; and failed to follow established standard precautions to prevent the transmission of infectious organisms. Also, the facility failed to test newly-admitted residents…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-08-12 · tag F0576 — patternEnsure residents have reasonable access to and privacy in their use of communication methods.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and review of the facility's policy, it was determined the facility failed to ensure residents had the right to receive mail delivered to the facility on Saturdays. The findings include: Review of the facility's policy titled, Resident Rights, not dated, revealed residents had the right to send and receive mail, and the facility was responsible for protecting and facilitating the resident's right to communicate with individuals and entities within and external to the facility. During the Resident Group Interview, on 08/09/2022 at 2:00 PM, the State Survey Agency (SSA) Surveyor interviewed the residents to see if they received mail at the facility, to include mail on Saturdays. The general consensus was residents did not receive mail on Saturdays, with the only exception being when mail or packages were delivered for special occasions such as residents' birthdays. Resident #29 stated and other residents agreed that staff did not generally deliver mail on Saturdays. Resident #29 stated during the week, mail was delivered by the Activities staff, but they were not…
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.
Show the remaining 6 citations
- Potential for harm · E2022-08-12 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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
Based on observation, interview, and review of the facility's policies, it was determined the facility failed to ensure residents had a safe, clean, comfortable and homelike environment. Residents complained during resident council of staff smoking outside on facility grounds. Observation revealed evidence of smoking off the Unit 2 exit, in the back parking lot, and at the back stairs. The findings include: Review of the facility's policy titled, Smoking Policy - Residents, not dated, revealed the facility was a no smoking facility. The policy stated smoking was only permitted if residents were off the premises. Review of the facility's policy titled, Resident Rights, not dated, revealed residents had the right to a safe, clean, comfortable, and homelike environment. Interview with the Resident Group, on 08/09/2022 at 2:00 PM, revealed Residents #65, #88, #29, and #57 complained of staff that provided care for them smelled of smoke, and they, as residents, were not allowed to smoke. Resident #88 stated he/she had observed four (4) or five (5) staff smoking outside the after hours…
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.
- Potential for harm · E2022-08-12 · tag F0835 — failed to run the facility competently — patternAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of the Director of Nursing and the Administrator's Job Descriptions, and review of the facility's policy, it was determined the facility failed to ensure it was administered in a manner to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident; and, failed to ensure infection prevention and control policies and protocols were adhered to for the safety and well being of residents, staff, and visitors. The Administration failed to ensure staff followed the Centers for Disease Control and Prevention (CDC) guidelines and the facility's policies for infection control and prevention (IPC); and COVID-19 testing was conducted per established local, state, and federal regulations. In addition, the Administration failed to ensure that all staff had received his/her primary vaccine series for COVID-19 per CDC guidelines because four (4) declination forms could not be…
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.
- Potential for harm · E2022-08-12 · tag F0867 — failed to act on quality-improvement findings — patternSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) Program that developed and implemented appropriate plans of action to correct quality deficiencies. Quality deficiencies were evidenced by the facility's failure to establish and maintain an infection prevention and control (IPC) program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases, including COVID-19. Multiple breaches of infection prevention and control practices, as stipulated by the Centers for Disease Control and the facility's policies, was observed from 08/08/2022 to 08/11/2022. In addition, COVID-19 testing was not conducted per established local, state, and federal regulations. Furthermore, all staff had not received his/her primary vaccine series for COVID-19 per CDC guidelines because four (4)…
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.
- Potential for harm · E2022-08-12 · tag F0888 — patternEnsure staff are vaccinated for COVID-19
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 have documented evidence of COVID-19 vaccination exemptions for those employees who declined to be vaccinated or whose vaccination status was unknown, for State Registered Nurse Aides (SRNA) #19, #20, #21, and Licensed Practical Nurse (LPN) #10. The findings include: Review of the Centers for Disease Control and Prevention's (CDC) memo titled, Long-Term Care and Skilled Nursing Facility Attachment A Revised, supplement to the QSO 22-07-ALL memorandum, revised 01/22/2022, revealed the facility must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. Per the memorandum, staff was considered fully vaccinated if it had been two (2) weeks or more since they completed a primary vaccination series for COVID-19. Furthermore, the policies and procedures must include a process for ensuring all staff, except for those that had been granted exemptions to the vaccination requirements of this section, had received, at a minimum, a single-dose COVID-19…
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.
- Potential for harm · Dcited before2022-08-12 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, and review of the facility's policies, it was determined the facility failed to develop and implement a comprehensive person-centered care plan in the care area of nutrition, for one (1) of thirty-two (32) sampled residents (Resident #26). The findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 2001 and revised December 2016, revealed a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was developed and implemented for each resident. Review of the Centers for Medicare and Medicaid Services (CMS), Resident Assessment Instrument (RAI) Manual 3.0, dated October 2017, revealed the Comprehensive Care Plan was an interdisciplinary communication tool and must include measurable objectives and time frames and must describe the services to be furnished to attain or maintain the resident'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.
- Potential for harm · D2022-08-12 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 Centers for Disease Control and Prevention's (CDC) document, review of the United States Pharmacopoeia Standards, review of a medication package insert, https://www.humalog.com/u100, and review of the facility's policy, it was determined the facility failed to ensure drugs, biologicals, and vaccines were stored per currently accepted professional principles and failed to ensure appropriate environmental controls were used to preserve their integrity. This deficient practice was found in two (2) of two (2) medication storage rooms and one (1) of three (3) medication carts. Observation of two (2) medication storage refrigerators located on Unit 1 and Unit 2, on [DATE], revealed the medication refrigerators' temperatures were not maintained between 36- and 46-degrees Fahrenheit (F). Further observation of Unit 1's medication storage refrigerator revealed vaccines and medications were stored improperly in the door of the refrigerator. Continued observations revealed 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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to PACS GROUP — 274 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.9 | -0.9 vs chain |
| Health inspection | 3 of 5 | 2.5 | +0.5 vs chain |
| Staffing | 1 of 5 | 2.5 | -1.5 vs chain |
| Quality measures | 4 of 5 | 4.4 | -0.4 vs chain |
The other 273 homes this chain runs (chain average 2.9★, per CMS)
Showing 40 of 273; 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 / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| PROVIDENCE GROUP OF KENTUCKY LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 02/03/2014 |
| PROVIDENCE GROUP NH, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | 100% | since 06/30/2023 |
| RICHARD, JOHN | Individual | CONTRACTED MANAGING EMPLOYEE | — | since 01/01/2015 |
| TIPPETTS, TANNER | Individual | W-2 MANAGING EMPLOYEE | — | since 08/10/2020 |
| APT, FREDERICK | Individual | CORPORATE OFFICER | — | since 01/01/2024 |
| HANCOCK, MARK | Individual | CORPORATE OFFICER | — | since 01/01/2024 |
| JERGENSEN, JOSHUA | Individual | CORPORATE OFFICER | — | since 01/01/2024 |
| MITCHELL, JOHN | Individual | CORPORATE OFFICER | — | since 01/01/2024 |
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.
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 $745K 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
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
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.
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 185215. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-05, 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.