Signature Healthcare of East Louisville
2529 Six Mile Lane, Louisville, KY 40220 · For profit - Limited Liability company · 128 certified beds · (502) 491-5560 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0606), cited Aug 2024
- inspectors cited 2 immediate-jeopardy problems — the most serious level
- a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $10,364 in federal fines (most recent 2025-01-03)
- its facility-reported quality-measure score sits well above its independent inspection score
- its independent health-inspection rating is low (2/5)
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 | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
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 | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 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 | 5.2% | 13.8% | 15.4% | better |
| Long-stay residents who lose too much weight | 12.7% | 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 | 0.3% | 1.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 58.0% | 17.7% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.5% | 0.2% | 0.1% | worse |
| Long-stay residents with falls causing major injury | 2.1% | 3.9% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 4.4% | 14.0% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 18.9% | 29.8% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 8.2% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 25.1% | 19.0% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 6.0% | 16.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.6% | 1.7% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 77.8% | 83.5% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 29.0% | 24.2% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 6.8% | 13.7% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 2.17 | 1.94 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.21 | 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.
58.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 151 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 40.5% 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 42 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 0.31 therapist hours per resident per day in 2026Q1 — more than 51% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 19% 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 | 58.0%CMS range 48.6–66.0 | 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 | 11.7%CMS range 8.8–15.1 | 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 | 40.5% | 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 | 40.5% | 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 | 30.9% | 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 | 97.6% | 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 | 95.2% | 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 | 1.2% | 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 | 2.4% | 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 | 6.2%CMS range 4.0–9.6 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.79 | 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 128 beds and averages 111.5 residents a day — about 87% occupied, or roughly 16 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.37 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.03 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.34 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 3.62 hrs/resident/day on weekends vs 4.68 on weekdays — 23% thinner on weekends — a notable drop. RN hours go from 1.11 to 0.83 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 55% is about the same as the national median of 45%. 1 administrator has left in the past year.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.
- Immediate jeopardy · Jcited before2025-01-03 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of facility's policy, the facility failed to develop and implement the care plan for one of three sampled residents, Residient (R) 1. On 01/22/2024, R1 became a ward of the state and was deemed as wholly disabled. She required assistance with managing both her personal and financial affairs. The facility, however, failed to develop the resident's care plan to include her becoming a ward of the state. On 09/17/2024, the resident exhibited exit-seeking behaviors and was placed on 15 minute checks, however, the facility failed to develop the resident's care plan to include the exit-seeking behaviors. Further, interview with facility staff revealed the resident roamed throughout the facility with personal items in her wheelchair or on her walker and verbalized delusions of going home. The facility, however, failed to develop the resident's care plan to include her behaviors of roaming and expressions of wanting to leave the facility. On 11/27/2024, exact time…
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.
- Immediate jeopardy · Jcited before2025-01-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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, facility document review, facility policy review and Google Maps review, the facility failed to provide residents with adequate supervision to prevent elopement for one of three sampled residents, Resident (R)1. R1 became a ward of the state on 01/22/2024 and although the resident had a Brief Interview of Mental Status (BIMS) score of 15 (indicating cognitively intact), the resident was legally deemed wholly disabled for managing both personal and financial resources, including the right to vote, and required supervision when leaving the facility. The facility, however, failed to ensure staff were aware the resident could not exit the facility unsupervised. On 11/27/2024, exact time unknown, R1 exited the facility through the main entrance after informing the employee working at the reception desk that she was going to step outside. The employee working the reception desk allowed R1 to exit the building. At approximately 12:15 PM, on the same day, R1 was observed…
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 before2024-08-23 · 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, review of the U.S. Food and Drug Administration (FDA) Food Code, 2022, and review of the facility's policies, it was determined the facility failed to store food in accordance with professional standards for food service safety. During observation on 08/20/2024 of the kitchen walk in refrigerator, multiple produce items were rotting. Additionally, multiple sleeves of bread were found with no label or expiration date. Also, leftover tomatoes were observed in container with no use by date. The findings include: Review of the facility's policy, Food Storage: Cold Foods, revised 02/2023, revealed all Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, were to be appropriately stored in accordance with guidelines of the Food and Drug Administration (FDA) Food Code. Further review revealed all foods were to be stored, wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the facility's policy, Food Storage: Dry Goods, revised 02/2023, revealed all dry goods were to 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 · Fcited before2024-08-23 · 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 Based on observation, interview, and review of standard of practice reference, it was determined the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of six sampled residents, Resident (R) 65. Observation of medication administration revealed Registered Nurse (RN) 7 failed to perform hand hygiene after administering medications for the resident, and prior to preparing medications for another. The findings include: Review of the facility's reference book, Fundamentals of Nursing, 10th Edition, by [NAME] and [NAME], pages 439 and 618, revealed the most effective basic technique for preventing and controlling the transmission of infection was hand hygiene. Per review, hand hygiene was defined as a general term that applied to four techniques: handwashing, antiseptic hand wash, antiseptic hand rub, or surgical hand…
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 · E2024-08-23 · tag F0606 — failed to not employ staff found guilty of abuse — patternNot hire anyone with a finding of abuse, neglect, exploitation, or theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, personnel record review, and facility policy review, the facility failed to ensure it had a process in place to ensure contracted employees had the Kentucky Adult Caregiver Misconduct Registry checked as required by KRS 209.032 for 2 of 5 employee files sampled. The findings include: Review of the facility policy Abuse, Neglect, and Misappropriation of Property revised 09/15/2023 revealed the facility included screening to provide protection for the health, welfare, and rights of each resident residing in the facility. Continued review revealed the screening included conducting criminal background checks and a search of the State Nurse Aide Abuse Registry. Review further revealed however, the Kentucky Adult Caregiver Misconduct Registry (KACMR) checks were not included as part of the screening. Review of the Kentucky Revised Statutes (KRS) 209.032 revealed a vulnerable adult services provider, such as a long term care facility was to, Query as to whether prospective or current employee has validated substantiated finding of adult abuse, neglect, or exploitation…
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 · Ecited before2024-08-23 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and facility policy review, the facility failed to ensure drugs and biologicals were stored in accordance with State and Federal laws for one (1) of three (3) facility medication storage refrigerators. In addition, the facility also failed to ensure medications were secured during medication administration for 1 medication cart. Observation of the medication room on the facility's 100 unit revealed a personal lunch bag with food and drinks stored inside the locked medication refrigerator located in the room. Additionally, observation revealed Registered Nurse (RN) 7 prepared a resident's medications, then stepped away from the medication cart leaving the pills in a medication cup unattended, and out of view of staff. The findings include: Review of the facility policy, Medication Administration, last revised 6/24/2024, revealed medications were administered as prescribed in accordance with manufacturers' specifications. Continued review revealed medications were also administered…
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 · F2019-11-16 · tag F0802 — failed to prepare enough nourishing food — widespreadProvide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of facility policy it was determined the facility failed to employ sufficient dietary staff with the appropriate competencies and skill sets to carry out the functions of food and nutrition service for 96 residents nine (nine residents received tube feeding) of 105 residents who received meals at the facility. Review of the Resident Census and Conditions of Residents, signed by the DON (Director of Nursing) on 11/12/19 revealed there were one hundred five (105) total residents and nine (9) residents received tube feeding. Observation and interview revealed there was not enough dietary staff to ensure meals were served to residents in a timely manner, per the facility posted meal times. (Refer to F809). In addition, resident food allergies and intolerances were not followed for Resident #79 with regards to gluten free diet and dietary staff interview revealed no training on gluten free diets. (Refer to F806). Frosted Spice Cake was not served per the menu on 11/12/19, per interview, due to lack of staff (Refer to F803). 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 · F2019-11-16 · tag F0809 — failed to serve meals on a reasonable schedule — widespreadEnsure 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 record review it was determined the facility failed to provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. Review of the facility posted Meal Times, which was not dated, revealed the lunch meal was to be served to the Gold/Main Dining Room at 12:30 PM. Observations during the meal service on 11/12/19 revealed the lunch meal was served late. Interviews with Resident's #18, #22, #28, and #155, revealed meals were often served late. Interview with Resident #155 revealed he/she would refuse prescribed short acting insulin until he/she knew for sure the trays were on the unit, due to the short acting insulin would make his/her sugar drop. The findings include: Review of the facility Meal Times, undated, revealed the lunch meal times for the Gold/Main Dining Room was at 12:30 PM. Further review revealed 200 Hall lunch was at 11:30 AM. Per the Meal Times…
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 before2019-11-16 · 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 Policies, it was determined the facility failed to prepare, store, distribute and serve food in accordance with professional standards for food service safety. Observation of the kitchen, on 11/12/19 revealed low fat cottage cheese with an open date 10/27/19, and turkey, which was labeled with two labels, one label documenting use by 10/7/19 and one label with the date 11/5/19, and a use by date of 11/20/19. Continued observation revealed chocolate pudding, dated to use by 11/10/19, an opened gallon of 2 percent milk with manufacturer use by date of 11/10/19, and potato salad opened 11/07/19. Furthermore, observation on 11/12/19 revealed ground pepper and ginger powder opened with no date, ground cumin dated opened 05/15/18, Mediterranean ground oregano labeled 09/22/17, and black pepper, which was not dated and the label was such that the date received could not be read. Observations revealed sugar, rice and flour bins were observed with brown substance on the containers. Moreover, observations of the walk in freezer on…
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 · Ecited before2019-11-16 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 5. (Refer to F689) Review of the clinical record revealed the facility admitted Resident #9 on 05/23/11. Record review revealed Resident #9 had diagnoses which included Dementia in other diseases classified elsewhere with behavioral disturbance; Displaced fracture of left radial styloid process, subsequent encounter for closed fracture with routine healing; Muscle weakness; and Difficulty in walking, not otherwise classified. Review of the MDS (Minimum Data Set) assessment dated [DATE], a Significant Change assessment, revealed the facility assessed Resident #9 as having a BIMS (Brief Interview Mental Status) score of eleven (11) out of fifteen (15). Per the MDS Assessment, the facility assessed Resident #9 as independent with no setup or physical help from staff for ambulating in room and corridor. Continued review revealed Resident #9 was assessed as having one (1) fall with major injury since the prior assessment. Review of the Quarterly MDS Assessment, dated 11/04/19, revealed the facility assessed Resident…
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 · D2019-11-16 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview it was determined the facility failed to provide treatment and care for one (1) of the thirty (30) sampled residents, Resident #51. Resident #51 had a physician order to be sent to the emergency room because the resident had complained of chest pain and was not sent until the following day. The physician was not notified until the next day that Resident #51 did not go out to the emergency room as the physician had ordered. The findings include: Review of Resident #51's clinical record revealed the facility admitted the resident 06/16/17 and readmitted the resident on 10/21/19, with diagnosis of sepsis, pulmonary embolism, chronic respiratory failure, and chronic obstructive pulmonary disease. In addition, resident has intellectual diagnosis of borderline intellectual functioning, Alzheimer's disease, dementia and cognitive impairment. Review of Resident #51's annual Minimum Data Set, dated [DATE], revealed the facility assessed the resident with a Brief…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-11-16 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor 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 record review it was determined the facility failed to maintain a homelike environment for two (2) of three (3) units. Observations and interviews revealed the facility had an odor of urine and the resident shower rooms for two (2) of three (3) units, had toilets with identified fecal matter. In addition, metal poles used in resident rooms were rusted and caked with white sticky matter. The findings include: The facility did not provide a policy for homelike conditions upon request. Review of the facility's policy, Maintenance Service, dated January 2005, revealed the maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Observation, on 11/12/19 at 09:50 AM, revealed physical entry to the 100 hallway had an odor of ammonia. Observation, on 11/12/19 at 10:48 AM, upon physical passage through the facility door to the residential area by the dining hall entrance, revealed a strong musty ammonia odor. Continued observation of the two-hundred (200) hallway again…
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 13 citations
- Potential for harm · D2019-11-16 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's Policy, it was determined the facility failed to provide written information to the resident or resident representative that specifies the duration of the state bed-hold policy for two (2) of thirty (30) sampled residents (Resident #16 and Resident #55). Record review revealed Resident #16 was transferred to the hospital for evaluation following a change of condition on 10/31/19; however, there was no documented evidence the facility provided the resident or the resident's representative written information related to the facility's Bed-hold Policy. Review of the medical record revealed Resident #55 was sent to the hospital for evaluation following a change of condition on 09/25/19; however, there was no documented evidence the facility provided the resident or the resident's representative written information related to the facility's Bed-hold Policy. The findings include: Review of the facility's Facility Bedhold Policy, dated revised 11/12/18,…
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 · D2019-11-16 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interview it was determined the facility failed to revise a comprehensive care plan for three (3) of the thirty (30) sampled residents. Resident #55 had a care plan for elimination however it was not revised to include the Foley catheter. Resident #79 had a care plan for nutrition however it was not revised to include the gluten free and lactose free allergies. Resident #9 had a care plan that was not updated to include dental status. The findings include: Record review of the facility policy titled, Comprehensive Care plans last revised on 07/19/18, revealed a person-centered comprehensive care plan would be developed for each resident and that would assist the facility on how to meet the residents needs. Record review further revealed the care plans were ongoing and revised as the resident had changes. The policy further revealed the nurse/Interdisciplinary Team was responsible for updating the care plans. 1. Interview with Resident #79 during the initial tour, on…
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 · D2019-11-16 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interview it was determined the facility failed to provide an ongoing program of activities for two (2) of the thirty (30) sampled residents from the care areas. Resident #90 and Resident #35 were to have facility provided activities, however, were observed to stay in their rooms with no activities provided. The findings include: Record review of the facility policy titled, Activity Program which was last revised on 07/25/17, revealed the facility would provide an on-going activities program designed to support the interest and choice of the residents. It further revealed the activity program was to help the resident obtain the highest level of mental, physical, and cognitive needs. In addition individualized and group activities were meant to encourage meaningful interacts to enhance the resident's sense of well-being. The policy further revealed residents were invited and encouraged to participate in activities. Record review of the facility policy titled, One-to-One…
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 · D2019-11-16 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview it was determined the facility failed to provide treatment and care for one (1) of the thirty (30) sampled residents, Resident #70. Resident #70 was to have his/her leg wrapped with an ace wrap and this was not done consistently. The findings include: Record review of the facility policy titled, Review of Physician Orders last revised on 11/06/19, revealed the Director of Nursing /designee would review the Electronic Medical Record (EMR) regarding documentation to support a change in condition and appropriate measures were provided, Record review of the clinical record revealed the facility admitted Resident #70 on 09/28/18 with diagnoses of Atherosclerotic Heart Disease, Cerebral Infarction, Hypertension, Diabetes Mellitus, Dysphagia, Psychotic Disorder with Delusions, Wound Myiasis, Excoriation disorder, and Non Specific Skin Eruptions. Record review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/29/19 revealed Resident #70 had a Brief Interview of Mental Status (BIMS) score of thirteen (13)…
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 · D2019-11-16 · 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 observation, interview, and record review it was determined the facility failed to provide care to prevent the development of pressure ulcers for one (1) resident of the thirty (30) sampled residents. Resident # 35 was to have heel lift boots on at all times, except when transferring or in a wheelchair. Observations revealed Resident #35 did not have heel lift boots on for two days. The findings include: Record review of the facility policy, Pressure Ulcer (Injury) Treatment revised on 07/24/18, revealed the purpose of the policy was to provide guidelines for the prevention of additional pressure injuries. The policy further revealed pressure-relieving devices were to be implemented in conjunction of the resident's assessed needs. Observation on 11/14/19 at 9:45 AM, revealed Resident #35 was lying in bed on a Recovery Pressure Mattress. Licensed Practical Nurse (LPN) #1 was going to do his/her pressure sore treatment to the coccyx. Nurse Consultant #9 assisted LPN #1. Observation revealed Resident #35 did not have any pressure relieving devices on the feet before 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 · Dcited before2019-11-16 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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, record review, and interview and policy review it was determined the facility failed to ensure two (2) residents out of the thirty (30) sampled residents was free from potential falls, Resident #9 and #61. Resident #61 had a history of falls and was supposed to have non skid socks on to help prevent falls. Resident #9 was supposed to have a physical therapy (PT) evaluation done after a fall with a fracture and the PT evaluation was not done. In addition, the investigation of the fall was not comprehensive. The findings include: Record review of the facility policy titled, Falls last revised on 11/06/19, revealed the intent was to provide residents care to minimize the risk of falls and injury. The policy further revealed the care plan interventions would be implemented and evaluated. Review further revealed the care plan would be reviewed after each fall and revised as needed in accordance with the assessment. The Falls policy stated if a fall occurred the Interdisciplinary Team (IDT) would…
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 · D2019-11-16 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview and policy review it was determined the facility failed to provide services and assistance to prevent urinary tract infections and failed to have a diagnosis for Foley catheter use for two (2) residents out of the thirty (30) sampled residents, Resident #90 and #55. Resident #90 had complaints of urinary symptoms and the facility received an order to perform a urinalysis (UA), however, did not obtain the UA. Record review revealed Resident #55 was re-admitted to the facility on [DATE], with a Foley catheter and no documented evidence of a Physician's Order with a diagnosis for continuing the Foley Catheter after the re-admission. In addition, no documented evidence of monitoring or care for the catheter, and no interventions for the Foley catheter care on the resident's Comprehensive Care Plan. The findings include: Record review of the facility policy titled, Change of Condition last revised 11/06/19, revealed the facility would evaluate and document changes in 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.
- Potential for harm · D2019-11-16 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and review of policy it was determined the facility failed to ensure an individual and Comprehensive Care Plan (CCP) was developed to ensure individual care was provided for one (1) of twenty-seven (27) residents with the diagnosis of Dementia. The finding: The facility did not provide a policy for Dementia. Review of Alzheimer's Association Facts and Figures, dated 2015, revealed the diagnosis of Alzheimer's was a common form of Dementia. Dementia was classified as the neurocognitive disorder which caused cognitive decline and debilitated the person to complete basic care needs. Review of Minimum Data Set (MDS) job description, dated 03/2013, revealed the MDS coordinator ensured all Care Area Assessments (CAA's) were care planned to meet the needs of the individual. Review of Comprehensive Care Plan (CCP) policy, revised 07/19/18, revealed the facility CCP included measurable objectives and interventions to meet the individual's mental and psychological care needs to maintain optimum function and status. Review of Resident #26's clinical 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.
- Potential for harm · Dcited before2019-11-16 · 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
Based on observation, interview and record review it was determined the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for one (1) of three (3) units. Observation of the 100 hall Nourishment Refrigerator on 11/16/19 revealed medications were stored in the nourishment refrigerator with foods. Continued observation revealed eleven (11) unopened insulin pens, five (5) individual dose influenza vaccines, multiple suppositories for nine (9) residents and one (1) box of Perforomist inhalation solution for one (1) resident. The Findings Include: Review of the facility policy titled Medication Storage Storage of Medication 4.1, dated 09/18 revealed medications and biologicals…
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 · D2019-11-16 · tag F0791 — failed to provide routine dental services — isolatedProvide or obtain dental services for each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of facility policy it was determined the facility failed to ensure residents were provided or obtained from an outside resource, dental services to meet the needs of each resident, to include routine dental services (to the extent covered under the State plan), and assist the resident in making appointments; and arranging for transportation to and from the dental services locations for one (1) of thirty (30) sampled residents (Resident #9). Resident #9 was evaluated by the dentist on 07/18/19, and received a referral to Oral Surgery for extractions. There was no evidence the resident was seen by Oral Surgery as of 11/16/19. The Findings Include: Review of facility policy titled Dental Services, dated last reviewed 06/05/18, revealed the facility must assist residents in obtaining routine and twenty four (24) hour emergency dental care. Per policy, routine and emergency dental services were provided to residents through a contract with a local dentist, referral to 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 · D2019-11-16 · tag F0806 — failed to honor food preferences — isolatedEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review and review of facility policy it was determined the facility failed to ensure each resident received and the facility provided food that accommodated resident allergies, intolerances, and preferences for one (1) of thirty (30) sampled residents (Resident #79). Observation during tray line on 11/13/19 revealed regular bread was placed on the tray for Resident #79, who was ordered a gluten free diet. The Findings Include: Review of the facility policy Food Allergy/Intolerance Awareness, dated revised 08/31/18, revealed food that accommodates resident allergies, intolerances, and preferences should be prepared and served. Continued review of the policy revealed a food substitute for the food allergy, intolerance, or preference should be consistent with the usual or ordinary food item provided to the community. Observation during the tray line beginning, on 11/13/19 at 11:30 AM, revealed Dietary Aide #2 was observed to place regular bread on the tray for Resident #79, and placed the tray on the cart for delivery. Interview with Dietary Aide…
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 · D2019-11-16 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and facility policy review, it was determined the facility failed to maintain an accurate and complete clinical record for one (1) of thirty (30) sampled residents, Resident #51. Record review revealed a physician order, dated 8/31/19, for the facility to transport Resident #51 to the emergency room. Further review revealed no documented evidence the facility staff communicated with the physician after emergency services would not transport the resident. The findings include: Review of the facility's policy, Charting and Documentation, revised 07/02/18, revealed any services provided to the resident, or any changes in the resident's medical condition, were document in the resident's medical record. Furthermore, the policy reveals documentation of procedures and treatments should include the minimum: the name and title of the procedure/treatment provided, the assessment data and/or any unusual findings obtained during the procedure/treatment, how the resident…
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 before2019-11-16 · 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, record review, and interview it was determined the facility failed to maintain an infection prevention program that was to provide a sanitary environment and help prevent the transmission of disease and infections for one (1) resident out of the thirty (30) sampled residents. Staff was observed to provide care to Resident #61 and did not wash or sanitize their hands after care. In addition the same staff was observed to throw linens on the floor that had urine in them. The findings include: Record review of the facility policy titled, Handwashing/Hand Hygiene revised on August 2015, revealed all personnel should follow handwashing/hand hygiene procedures to help prevent the spread of disease. The policy further stated staff should use alcohol-based hand rub or alternatively soap and water before and after contact with residents, after contact with a resident's intact skin, after removing gloves, and after contact with objects in the immediate vicinity of the resident. Review further…
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
$10,364 in federal fines across 2 penalties.
- $5,182 — penalty dated 2025-01-03
- $5,182 — penalty dated 2025-01-03
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to SIGNATURE HEALTHCARE — 67 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 | 3.1 | -1.1 vs chain |
| Health inspection | 2 of 5 | 2.9 | -0.9 vs chain |
| Staffing | 3 of 5 | 2.8 | +0.2 vs chain |
| Quality measures | 4 of 5 | 3.9 | +0.1 vs chain |
The other 66 homes this chain runs (chain average 3.1★, per CMS)
Showing 40 of 66; 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 |
|---|---|---|---|---|
| LP CR HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 11/01/2007 |
| AGEMO HOLDINGS LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/01/2016 |
| JJLA LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/01/2007 |
| LPSNF II LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 10/01/2016 |
| WHEATEN LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/01/2007 |
| STEIER III, ELMER | Individual | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 11/01/2007 |
| MEREDITH, KARA | Individual | W-2 MANAGING EMPLOYEE | — | since 04/01/2024 |
| HARRISON, JOHN | Individual | CORPORATE OFFICER | — | since 11/01/2007 |
5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
About 74% 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 $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 13% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. 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
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 185350. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-12, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
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