Chestnut Ridge Health & Rehabilitation

Location & what’s nearby

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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

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.

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.

Therapy staffing: this home’s payroll records show 0.15 therapist hours per resident per day in 2026Q1 — more than 12% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. 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.

Staffing

How full it usually is: this home is certified for 92 beds and averages 71.4 residents a day — about 78% occupied, or roughly 21 beds typically open. It usually has some room. 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 3.40 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.79 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.02 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 3.10 hrs/resident/day on weekends vs 3.53 on weekdays — 12% thinner on weekends. RN hours go from 0.82 to 0.72 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 61% is well above the national median of 45%.

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

Inspection trend

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.

32 citations, most serious first. The 17 most serious are shown; the remaining 15 are one tap away and print in full.

• Immediate jeopardy · Jcited before2025-12-13 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive, individualized care plan that accurately reflected the nutritional and dietary needs for 1 of 7 residents sampled for dietary needs out of the total sample of 21 residents, (Resident (R)86). The facility failed to develop and ensure R86's care plans accurately reflected the resident's risk for choking, the Speech Therapy (ST) recommendations, dietary consistency requirements, and safe snack provisions consistent with the resident's physician's orders and with interventions necessary to address the risk. On 04/25/2025, Certified Nurse Aide (CNA) 11 gave R86 a peanut butter sandwich, the resident choked on the sandwich, became unresponsive, and eventually expired at the hospital. The official Kentucky Certificate of Death noted R86's immediate cause of death as choking on a food bolus (when an aspirated material occludes the upper airways resulting in the inability to breathe). Immediate Jeopardy (IJ) was identified on 09/19/2025 and was determined to exist as…

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

  Resident Assessment and Care Planning Deficiencies · Past Non-Compliance
• Immediate jeopardy · Jcited before2025-12-13 · tag F0803 — failed to meet residents' dietary needs — isolated
  Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review and review of the facility's policy, the facility failed to ensure residents received a therapeutic diet per the physician's order for 1 of 7 residents sampled for diets out of the total sample of 21 residents, (Resident (R)86). The physician ordered a pureed diet for R86; however, on 04/25/2025, a Certified Nurse Assistant (CNA) gave the resident a peanut butter sandwich. R86 choked on the sandwich and subsequently lost his pulse. The Emergency Medical Services (EMS) transferred R86 to a hospital where R86 expired. Review of the official Kentucky Certificate of Death listed the immediate cause of death as, choking on a food bolus. Immediate Jeopardy was identified on 09/19/2025 and was determined to exist as of 04/25/2025 (the day R86 choked on the sandwich), in the area of 42 CFR 483.60, Food and Nutrition Services. The Administrator was notified of the Immediate Jeopardy on 09/19/2025 at 6:01 PM and provided a copy of the CMS IJ Template and was notified that the facility failed to have a system to ensure residents received physician ordered,…

  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 · Past Non-Compliance
• Immediate jeopardy · Kcited before2023-08-07 · tag F0656 — failed to write and follow a full care plan — pattern
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 9. Review of Resident #84's medical record revealed the facility admitted the resident on 05/03/32023, with diagnoses of Post-Traumatic Stress Disorder, Chronic Obstructive Pulmonary Disease, Anxiety, and Diabetes Mellitus type 2. Review of the admission MDS assessment dated [DATE] revealed the facility assessed Resident #84 as having a BIMS score of fifteen (15) out of fifteen (15) indicating he/she was cognitively intact. Continued MDS review of section I, revealed Resident #84 triggered for Post Traumatic Disorder (PTSD). Review of Resident #84's Comprehensive Care Plan dated 05/16/2023 revealed no documented evidence of care plan formulated for the resident's PTSD. Continued review of the Comprehensive Care Plan revealed a list of diagnoses under Resident #84's potential nutrition problem dated 05/16/2023, which listed PTSD with the resident's other diagnoses. In interview on 08/06/2023 at 9:42 AM, the DON stated she was not aware Resident #84 had a diagnosis of PTSD. The DON stated a care plan should have…

  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
• Immediate jeopardy · Kcited before2023-08-07 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  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 policy, it was determined the facility failed to have an effective system in place to ensure adequate supervision and monitoring to prevent falls and accident hazards for four (4) of sixty-one (61) sampled residents, Residents #6, #15, #51, and #72. Observation on 07/23/2023, revealed Resident #6 being transferred by a mechanical lift with the assistance of one (1) staff member. The facility assessed Resident #6 to require extensive assistance of two (2) staff to move between surfaces on 06/21/2023. Record review revealed Resident #15 had a fall on 06/28/2023 and was diagnosed with a right hip fracture on 07/07/2023. Review revealed Resident #15 was noted to be rolling to the edge of the bed on 07/28/2023. Further record review revealed Resident #15 fell from his/her bed on 07/28/2023. Record review revealed Resident #51 sustained ten (10) falls after his/her admission to the facility on [DATE] through 07/08/2023. Review of medical record…

  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
• Immediate jeopardy · J2023-08-07 · tag F0698 — failed to provide proper dialysis care — isolated
  Provide safe, appropriate dialysis care/services for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents, who required dialysis/hemodialysis received such services, consistent with professional standards of practice for four (4) of nineteen (19) sampled residents who received dialysis (Residents #242, #243, #244, and #11). In addition, the facility failed to ensure communication sheets, used to communicate information on the resident, were completed for each dialysis treatment. 1. The facility failded to secure and set-up Resident #243's dialysis treatments prior to admission to the facility on [DATE]. The facility failed to ensure Resident #243 received his/her dialysis treatment on 07/12/2023. The resident was discharged on 07/14/2023, and transported to the hospital for acute care dialysis. 2. The facility failed to ensure Resident #242 received his/her dialysis treatments on 04/23/2022, 04/26/2022, and on 04/28/2022. On 04/28/2022, when Resident #242 arrived to his/her dialysis…

  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
• Actual harm · Gcited before2023-12-19 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to have an effective system in place to ensure residents' care plans were implemented to provide the proper care, monitoring and documentation to enable residents to have effective coping skills for one (1) of thirteen (13) sampled residents (Resident (R) 6). On 12/14/2023, R6 threw coffee on R8 and R8 sustained an open blister/burn on his/her upper chest. Documentation provided by the facility revealed it failed to implement R6's comprehensive care plan to monitor the resident's behaviors and document observed behaviors, and attempted interventions after facility staff documented R6 was having behaviors on 08/09/2023. Staff learned on 12/13/2023 that R6 wrote a note on his/her notepad, which he/she showed to the Minimum Data Set (MDS) Coordinator, and the note indicated R8 called him/her a bitch. Additionally, it was not validated R6's care plan was implemented as written, as there was no documentation noting the facility assessed R6's understanding of the…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-12-19 · tag F0740 — failed to provide behavioral / mental-health care — isolated
  Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to provide necessary behavioral health services to thoroughly address the physical, mental, and psychosocial needs for one (1) of thirteen (13) sampled residents (Resident 6). On 08/09/2023, Resident (R) 6, exhibited behaviors that initiated a Behavior Comprehensive Care Plan (CCP), on 08/10/2023, for staff to monitor and document R6's observed behaviors. Staff; however, were unable to recall the behavior that prompted the resident's care plan, and the behavior was not addressed in the Behavior Logbook or Behavior Charting. On 12/12/2023, the resident expressed to staff that R8 was calling him/her inappropriate names, and on 12/13/2023, the resident wrote a letter, in his/her notepad, indicating that if the facility did not address his/her concerns he/she would do something about R8. The resident's care plan was revised on 12/13/2023 for staff to ensure the resident felt safe and to ensure…

  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 · Ecited before2025-12-13 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review the facility failed to ensure it had an effective system to prevent the transmission of infection on 3 of 4 units for 5 of 21 sampled residents (R) 9, R12, R41, R63 and R77. The findings include:Review of the facility policy titled Infection Control Program, undated, stated the facility will establish and monitor environmental infection prevention and control practices in accordance with the Center for Disease Control (CDC), local and state requirements; develop isolation precaution protocols to control an infectious disease is required in accordance with current CDC guidelines and recommendations.The Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, facility policy, dated 09/23/2022 revealed if the facility has a resident with a positive test for COVID, or a resident with symptoms of COVID-19, or health care personnel with high risk exposure the facility will implement; a process to make everyone entering 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-12-13 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review, and facility documentation, the facility failed to complete all pre-employment checks for 2 of 8 sampled new employees' files, (a Dietary Aide and Activities Assistant). The findings include:Review of the facility's policy Abuse,' revised 10/20/2022, revealed the facility was committed to developing and operationalizing policies for screening employees and protection of residents. Further, under the section labeled Screening, the policy stated the organization will screen potential employees for a history of abuse, neglect or mistreating residents. Additionally, multi-state registry checks and license verifications will be checked from every State registry established that the facility believed will include information on the individual.Review of the personnel file for the Dietary Aide (DA) revealed the facility hired the DA on 09/05/2025. Review of the personnel file for the Activities Assistant (AA) revealed the facility hired the (AA) on 09/11/2025. However, continued review revealed no documentation the facility completed the Kentucky (KY)…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2023-10-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of the facility's investigation report, and review of the facility's policies, it was determined the facility failed to ensure a safe environment that was free from accidents and hazards to ensure resident safety and supervision for one (1) of thirty one (31) sampled residents (Resident #595). On 10/07/2023 at approximately 1:00 PM, Resident #595, whom the facility assessed to lack safety awareness, was seen by the Regional Director of Operations for Food/Nutrition Services, outside, behind the facility, sitting in his/her wheelchair near the street unsupervised by facility staff. By the time staff inside the facility were alerted by the Regional Director of Operations for Food/Nutrition Services, the resident was found two (2) blocks away from the facility. The findings include: Review of the facility's policy titled, Standard Supervision and Monitoring, dated 05/17/2023, revealed the general purpose of the policy emphasized a proactive intervention 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 · F2023-08-07 · tag F0725 — failed to have enough nursing staff — widespread
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, review of facility records and policy, it was determined the facility failed to ensure there were adequate, competent staff to ensure the safety of its residents. Observation on 08/07/2023 revealed three (3) Certified Nursing Assistants (CNAs) called off for day shift leaving one (1) CNA on the two hundred (200) hall. The findings include: Review of the facility's Staffing Guideline, revised on 05/11/2021, revealed during critical staffing periods there might be times when an incentive would be provided to nursing staff to work additional shifts outside their normal schedule. Review of the facility's Standard Staffing Supervision Monitoring Guideline Policy and Procedure, last reviewed 06/20/2023, revealed staff assignments were based on residents' needs as far as their acuity and their assessment results, and their person-centered care planning. Continued review revealed the requirement for meeting residents' needs to include physical, emotional, psychosocial, social, and spiritual, was to be accomplished by provision of as much hands on care as…

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

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2023-08-07 · tag F0803 — failed to meet residents' dietary needs — widespread
  Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and review of the facility's menus, it was determined the facility failed to follow its menus. Observation revealed the menus were not always followed as posted. In addition, portion sizes were not always used according to the guidance on the production sheets. The findings include: Review of the facility's guide titled, Portion Control Chart, undated, revealed the color for the scoop and disher (type of ladle) for accurate portion servings. Scoops number and color were noted as follows: #8 scoop was gray; #12 scoop was green; #16 was blue; and, the #24 scoop was green. Scoop numbers and portion size were noted as: #8 scoop equaled four (4) ounces; #12 scoop equaled two and two thirds (2 and 2/3) ounces; the #16 scoop equaled two (2) ounces; and the #24 scoop equaled one and one-third (1 and 1/3) ounces. Observation of the breakfast tray line on 07/25/2023 at 8:35 AM, revealed scoops used were as follows: the #12 green scoop (2 and 2/3 ounces) was used for pureed sausage instead of the #24 red scoop (1 and 1/3 ounces) per the production sheet; the…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2023-08-07 · 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, it was determined the facility failed to store, and prepare food under sanitary conditions. Observations, during the initial kitchen tour, revealed an ice scoop left stored in the ice machine; staff's personal drink cup was left sitting on the production table; and the snack room had food items not labeled and dated. Additionally, there was tube feeding, dated 04/01/2023, stored on a shelf available for use. The dishwasher temperature log was incomplete from 07/25/2023 to 07/30/2023. The findings include: Review of the facility's policy titled, Storage Periods, Use-By Guidelines, dated 05/25/2023, revealed foods with a manufacturer's use-by-date would still require an opened-on date once the item was opened. Continued review revealed all opened containers of food in the dry storage area were to be placed in an enclosed container, labeled, and dated. Further review revealed the expiration date was the last day the product was to be used for the best quality. 1. Observation on 07/24/2023 at 9:20 AM, during the…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-08-07 · tag F0550 — failed to protect resident dignity and rights — pattern
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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 ensure residents' right to a dignified existence and communication with and access to persons and services inside and outside the facility for four (4) of sixty-one (61) sampled residents (Residents #4, #40, #51, and #57). Resident #4 stated staff entered his/her room while he/she was having a private phone conversation with his/her family. Resident #40 stated staff members often turned his/her call light off, left the room not changing him/her, while telling the residents that all the residents were waiting to be changed. Observation revealed staff rolled his eyes at Resident #51 and stated how much he hated sitting with the resident in front of the resident. Resident #57 stated staff had been rude to him/her and laughed at him/her. The findings include: Review of the facility's policy, Resident Rights, revised 11/07/2022, revealed it was the policy of the facility to observe and…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-08-07 · tag F0600 — failed to protect residents from abuse and neglect — pattern
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to protect residents from physical and verbal abuse for seven (7) of sixty-one (61) sampled residents, Residents #2, #44, #243, #492, #493, #31, and #39. On 07/16/2022, staff responded to yelling and entered room shared by Resident #44, and Resident #492, witnessing Resident #492 yelling at Resident #44 and swinging an empty urinal at Resident #44. Resident #44 was covered in urine. On 04/17/2023, Resident #2 was observed pushing Resident #493 out of the doorway of Resident #2's room, causing Resident #493 to fall. On 07/13/2023, it was reported to the Administrator Resident #243 was at the nurses station upset and speaking loudly. When the Business Office Manager (BOM) asked Resident #243 what was wrong, Certified Nursing Assistant (CNA) #14 yelled that Resident #243 was an asshole. On 08/21/2022, Resident #31 made slight contact with Resident #39 at the Nurse's Station. The findings include:…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-08-07 · tag F0809 — failed to serve meals on a reasonable schedule — pattern
  Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
  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 mealtimes it was determined the facility failed to serve meals at regular times comparable to normal mealtimes in the community for eight (8) of twenty-seven (27) sampled residents (Residents #4, #40, #46, #55, #56, #71, #75, and #86) on the 400 Unit. Observations, during the survey, revealed breakfast, lunch and dinner meals were served two (2) hours after the posted mealtimes, on the 400 Unit. The residents did not receive dinner trays until 9:00 PM on 07/30/2023. In addition, interviews revealed the residents did not receive or were offered food from the always available menu. The findings include: Review of the facility's posted mealtimes titled, Mealtimes, not dated revealed Breakfast Dining room service was 7:00 AM; Lunch Dining room service was 12:00 PM; and, Dinner Dining room service was 5:00 PM. The breakdown of trays to the units, after the dining room was served, was to the 100 Unit Autumn; 200 Unit Evergreen; 300 Unit Lakeview; and then…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2023-08-07 · tag F0813 — pattern
  Have a policy regarding use and storage of foods brought to residents by family and other visitors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and review of the facility's policy, it was determined the facility failed to label and date residents' food items. Observations of the residents' refrigerator and freezer revealed unidentified or undated residents' food items. The findings include: Review of the facility's policy titled, Food Brought into Facility, dated 03/28/2023, revealed residents were allowed the enjoyment of foods brought into the facility by family and other visitors, while maintaining the safety and sanitation requirements for the residents as set forth by local, state, and federal regulations. Perishable food brought in by a resident, relative, and/or friend, should be eaten immediately or at the next meal. Outside foods requiring storage and refrigeration must be dated, labeled, and stored per the facility's and state's guidelines. Observation of the residents' refrigerator and freezer, on 07/26/2023 at 9:40 AM, revealed an ice pack, which was a non-food item, pushed into the back right corner and frosted. Continued observation of the freezer revealed one (1) vanilla ice…

  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

“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.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to LYON HEALTHCARE — 11 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 →

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

CMS files one row per role, so the 27 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

About 93% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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