Mt. Sterling Health & Rehab, LLC
125 Sterling Way, Mount Sterling, KY 40353 · For profit - Limited Liability company · 144 certified beds · (859) 498-3343 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0600), cited May 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $13,520 in federal fines (most recent 2025-10-22)
- its independent health-inspection rating is low (1/5)
- its payroll-based staffing rating is low (2/5)
- its facility-reported quality-measure rating is low (1/5)
- about 19% of its spending goes to commonly-owned related companies
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 1 of 5 |
| StaffingFrom payroll records (PBJ) | 2 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 1 of 5 |
| Long-stay residentspeople who live here | 1 of 5 |
| Short-stay residentsrehab / post-hospital | 2 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 25.2% | 13.8% | 15.4% | worse |
| Long-stay residents who lose too much weight | 8.6% | 6.6% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 1.0% | 0.5% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 2.3% | 1.6% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 9.8% | 17.7% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 5.8% | 3.9% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 19.1% | 14.0% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 32.7% | 29.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 6.9% | 4.8% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 23.4% | 19.0% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 28.0% | 16.1% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.8% | 1.7% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 100.0% | 83.5% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 29.6% | 24.2% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 12.1% | 13.7% | 12.0% | typical |
| Long-stay hospitalizations per 1,000 resident days | 2.57 | 1.94 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.64 | 2.14 | 1.80 | worse |
‡ 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.
56.0% 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 201 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 47.4% 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 78 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 0.37 therapist hours per resident per day in 2026Q1 — more than 63% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 25% 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 | 56.0%CMS range 49.5–63.0 | 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 | 12.9%CMS range 9.9–16.2 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 47.4% | 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 | 34.6% | 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 | 38.5% | 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 | 92.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.1% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.9% | 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 | 2.8% | 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 | 8.0%CMS range 5.6–11.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.94 | 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 144 beds and averages 125.1 residents a day — about 87% occupied, or roughly 19 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.85 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.34 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.65 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.52 hrs/resident/day on weekends vs 3.98 on weekdays — 12% thinner on weekends. RN hours go from 0.37 to 0.26 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are unchanged from the previous inspection. 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.
26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.
- Actual harm · Gcited before2025-11-14 · 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 interview, record review, review of the facility's investigation, and review of the facility's policies, the facility failed to ensure its staff practiced safe transfer techniques, utilizing a mechanical lift, to prevent injuries for 1 of 5 sampled residents, Resident (R) 1.On 04/02/2025, R1 was transferred from the bed to a chair by two State Registered Nurse Aides (SRNA) using a mechanical lift. SRNA4 was operating the lift, while SRNA1 was holding onto the lift pad during maneuvering. SRNA4 moved the lift from the bed to the chair, positioned the lift device under the chair, and failed to extend the legs, necessary for balancing the device. SRNA1 pulled on the lift pad to position R1 into the chair resulting in unbalanced weight distribution that caused the lift to tilt. The bar attachment struck R1 on the back of her head causing a laceration. R1 was transferred by ambulance to a local emergency room on [DATE] and required staples to close the wound.Based on review of the facility's plan of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2026-03-06 · tag F0578 — failed to honor advance directives / code status — patternHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, review of the facility's admission Packet, and review of the facility's policy, the facility failed to ensure residents were provided the right to formulate an advance directive for 12 of 19 sampled residents, Resident (R) 1, R2, R4, R6, R8, R10, R22, R37, R38, R54, R56, and R60. Seven residents had a Health Care Decision Making form on file, with six indicating they had advance directives. However, review of the documentation did not meet the requirements for advance directives. The findings include:Review of the facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives, not dated, revealed the facility would support and facilitate a resident's right to formulate an advance directive. The policy stated if requested, the facility would provide the resident or resident's representative information about the right to formulate an advance directive, and if a resident had an advance directive on admission, copies would be placed in the chart.Review of the facility's admission Packet revealed a form, Health Care Decision…
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 before2026-03-06 · 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 review of the facility's policies, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles and include the appropriate expiration date when applicable for 3 out of 8 medications carts, the Wisteria Unit medication cart 1 and medication cart 2 and the Lakeview Unit medication cart 1.Observations on [DATE] revealed three expired and/or undated eye drops in the Wisteria Unit's medication cart 1; seven expired and/or undated eye drops in the Wisteria Unit's medication cart 2; and one expired eye drop in the Lakeview Unit's medication cart 1.The findings include:Review of policy titled Storage of Medication Requiring Refrigeration not dated, revealed The facility will ensure that all drugs and biologicals used will be labeled in accordance with professional standards, including expiration dates (when applicable) and with appropriate accessary and precautionary instructions (such as shake well, take with meals, do not crush,…
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 before2026-03-06 · tag F0880 — failed to prevent and control infections — patternProvide 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, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility's policy, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases. The facility failed to implement its infection prevention and control policies and procedures and identify and correct problems relating to infection prevention practices for 6 out of 10 sampled residents, Resident (R) 11, R18, R38, R113, R122, and R133, who were cared for by staff who had not performed the required hand hygiene. The findings include:Review of the Centers for Disease Control and Prevention (CDC) guidelines Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated 04/12/2024, revealed hand hygiene should be performed immediately before providing 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 before2026-03-06 · 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, review of the facility's job description, and review of the facility's policies, the facility failed to provide adequate supervision and an environment free of accident and hazards for 3 of 5 sampled residents, Resident (R) 10, R82, and R60. Review of R82's electronic medical record (EMR) revealed on 05/19/2025 R82 was left unsupervised in the bathroom and fell. Review of R10's EMR revealed on 09/15/2025 R10 was sitting in a chair in the television area and fell while attempting to self-transfer. The resident sustained a fractured nose, abrasion to the right eyebrow, and complained of pain in the right shoulder.Observation on 03/03/2026 of R60 revealed a medication cup containing crushed medication mixed in pudding, with a spoon inside, was left on the bedside table in front of R60, who was awake and sitting in her wheelchair.The findings include:Review of the facility's policy titled, Fall Prevention Program, undated, revealed each resident would be assessed for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-03-06 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility's policies, the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with physician orders and professional standards of practice for 2 out of 3 sampled residents, Resident (R) 11 and R93.1. Observation on 03/03/2026 revealed R11's oxygen was set at 4.5 liters per minute (LPM) when his physician order was for continuous oxygen at 4.0 LPM. Further observation on 03/03/2026 and 03/05/2026 revealed the resident was not wearing his oxygen tubing and not receiving oxygen, and staff did not return to R11's room to place the oxygen back on the resident. 2. Observation on 03/03/2025 revealed R93's oxygen was set at 2 LPM and observation on 03/04/2026 revealed R93's oxygen was set at 3.5 LPM when her physician order was for continuous oxygen for 14 hours or more at 3.0 LPM via nasal cannula.The findings include:Review of the facility's undated policy titled, Oxygen Administration, revealed…
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 · D2026-03-06 · tag F0698 — failed to provide proper dialysis care — isolatedProvide 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
Based on interview, record review, and review of the facility's policy, the facility failed to provide residents who required dialysis services an ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility for 1 of 1 sampled resident who received dialysis services, Resident (R) 38.Record review revealed R38 received hemodialysis three times a week on Monday, Wednesday, and Friday. However, the facility provided incomplete documentation for pre-and-post dialysis assessments on the following dates: 02/04/2026, 02/05/2026, 02/16/2026, 02/23/2026, and 02/25/2026. Also, the facility did not provide ongoing assessment and monitoring for the months of January 2026 or March 2026.The findings include:Review of the facility's undated policy titled, Hemodialysis, revealed the facility would ensure each resident's care and services included an ongoing assessment and oversight of the resident before, during, and after treatments, including monitoring for complications and ongoing communication 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.
- Potential for harm · D2025-11-14 · 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
Based on interview, record review, and review of the facility's investigation, the facility failed to immediately notify the resident's representative (s) when there was an identified injury, an accident, or a significant change in the resident's physical status, for 1 of 1 sampled resident, Resident (R) 2. The findings include:Review of R2's admission Record revealed the facility admitted the resident on 02/28/2022 with diagnoses to include chronic lymphocytic leukemia (CLL) and chronic kidney disease. A diagnosis of contracture left hand was added on 11/26/2023.Review of R2's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 08/19/2025, revealed the facility assessed the resident as having a Brief Interview for Mental Status [BIMS] score of six out of 15, indicating severe cognitive impairment. R2 was further assessed as dependent on staff for most Activities of Daily Living (ADL), as well as dependent on staff for ambulation. Review of the facility's investigation into R2's bruising revealed a statement, dated 09/19/2025, from the Sterling Unit Manager…
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 · E2025-03-13 · tag F0623 — patternProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's documents and policy, the facility failed to notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood as soon as practicable. The facility further failed to ensure the notice included the reason, date, and location for the transfer, as well as a statement of the resident's appeal rights and the contact information for the state Long-Term Care Ombudsman. The deficient practice was identified for 8 out of 10 residents reviewed for transfer and/or discharge, Resident (R) 30, R35, R44, R62, R66, R68, R91, and R94. The findings include: Review of the facility's Transfer and Discharge (including AMA) policy, not dated, revealed, The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. 1. Review of R35's admission Record revealed the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-03-13 · tag F0625 — patternNotify 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 4. Review of R30's admission Record revealed the facility admitted the resident on 10/07/2021 with diagnoses of acute on chronic diastolic heart failure, chronic respiratory failure with hypercapnia, and COPD. Review of R30's Nurse's Note, dated 09/11/2024, revealed R30 had a decreased oxygen saturation of 78% on 5 Liters (L) per minute of oxygen and was sent to the emergency room (ER). Review of R30's Transfer to Hospital Summary, dated 10/16/2024, revealed the facility transferred the resident to the hospital on that date for oxygen saturation of 75% on 4 Liters (L) per minute via nasal cannula, wet lung sounds, and lethargy. Review of R30's Health Status Note, from 12/01/2024, revealed R30's oxygen saturation dropped to 71% after getting a nebulizer treatment which failed to stabilize R30's oxygen saturation. R30 was sent to the hospital. Review of R30's eInteract Transfer Form, dated 02/17/2025, revealed R30 was transferred to the hospital because her oxygen saturation was 85% on 4 Liters (L) per minute via…
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 before2025-03-13 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility's policies, the facility failed to establish or maintain an effective infection prevention and control program, which was essential for providing a safe, sanitary, and comfortable environment while preventing the development and spread of infectious diseases for 5 of 50 sampled residents, Resident (R) 30, R17, R74, F90, and R325. 1. Observation on 03/11/2025 and 03/12/2025 revealed R30's oxygen nasal cannula tubing was dated 02/18/2025, and the humidification water bottle was undated. 2. Observation on 03/11/2025 revealed State Registered Nurse Aide (SRNA) 3 and SRNA5 were seen not hand sanitizing between passing lunch trays for R17, R74, and R90. Further observation on 03/12/2025 revealed SRNA13 touched R90's food with no gloves on and hand hygiene not performed. 3. Observation on 03/12/2025 revealed SRNA8 and SRNA7 entered R325's room, who was on droplet precautions, performed resident care, then exited the room with the used, uncleaned…
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 15 citations
- Potential for harm · Dcited before2025-03-13 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of the facility's policies, the facility failed to develop and/or implement a Comprehensive Care Plan (CCP) to ensure it met the residents' medical, nursing, mental, and psychosocial needs as identified on his/her comprehensive assessment and other assessments for 2 of 26 sampled residents, Resident (R) 30 and R31. Review of R30's Comprehensive Care Plan [CCP] revealed staff failed to follow the interventions based on the physician's orders for the administration of oxygen. Review of R31's CCP revealed the facility failed to develop a care plan for R31's dialysis catheter. The findings include: Review of the facility's Comprehensive Care Plans policy, not dated, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-13 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure residents requiring respiratory care were provided such care consistent with professional standards of practice for 1 out of 3 residents sampled for respiratory care, Resident (R) 30. Observation on 03/11/2025 at 9:32 AM revealed R30's oxygen concentrator was set on 5 Liters (L) per minute via nasal cannula (NC), and on 03/12/2025 at 11:59 AM, R30's oxygen concentrator was set on 4.5 L per minute via NC. However, review of R30's Physician's Orders revealed R30 had orders for oxygen to be administrated continuously at 4 L per minute via NC. The findings include: Review of the facility's policy titled, Oxygen Administration, not dated, revealed oxygen was to be administered under orders of a physician, except in the case of an emergency. In such case, oxygen was administered and orders for oxygen were obtained as soon as practicable when the situation was under control. Review of R30's electronic medical record (EMR) admission Record revealed the facility admitted R30 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 · D2025-03-13 · tag F0865 — failed to run a quality-improvement (QAPI) program — isolatedHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, review of the facility's documents, and review of the facility's plan of correction (PoC), dated 05/27/2024, the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) process. The facility failed to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focused on indicators of the outcomes of care and quality of life that were achieved and sustained for 1 of 50 sampled residents, Resident (R) 325. Observation on 03/12/2025 at 9:21 AM revealed State Registered Nurse Aide (SRNA) 8 and SRNA7 entered R325's room, who was on droplet precautions, performed resident care, then exited the room with a used, uncleaned gait belt placed in SRNA7's pant pocket. Review of the previous survey, dated 04/30/2024 to 05/03/2024, revealed a repeat issue was found with equipment not being cleaned between resident use. Refer to F880 The findings include: Review of the facility's acceptable PoC, for the Standard Recertification/Abbreviated/Extended Survey, concluded on 05/03/2024, revealed the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-05-03 · tag F0761 — failed to label and store drugs safely — widespreadEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of the Centers for Disease Control and Prevention's (CDC) document, review of medication package inserts, and review of the facility's policy, it was determined the facility failed to ensure drugs, biologicals, and vaccines were stored per currently accepted professional principles and failed to ensure appropriate environmental controls were used to preserve their integrity. This deficient practice was found in three of four medication storage rooms. Observations of the facility's treatment carts revealed improper storage of medications was found in three of four treatment carts affecting nine residents, Resident (R) 30, R31, R34, R37, R43, R46, R58, R68, and R94. Observation of the Lakeview and Sterling Units' medication refrigerators revealed one influenza vaccine was improperly stored in the door of the medication refrigerators. Observation of the Sterling Unit's medication refrigerator revealed the medication refrigerator's temperature was not maintained between 36 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.
- Potential for harm · F2024-05-03 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and review of the facility's policy, the facility failed to store food under sanitary conditions for three of four nourishment unit refrigerators as determined by observations during survey of ice packs stored in two unit nourishment freezers, and one unit nourishment refrigerator with no thermometer, and no temperature log for April 2024. The findings include: Review of the facility's policy titled, Monitoring of Cooler/Freezer Temperature, dated 2024, revealed logs for recording temperatures for each refrigerator or freezer would be posted in a visible location outside the freezer or refrigerator unit. Further review revealed temperatures would be checked and logged at least twice per day by designated personnel, and thermometers shall be placed inside each cooler/freezer and calibrated at least once per week. Continued review revealed all refrigerator storage must be maintained at or below 41 degrees Fahrenheit (F), and all frozen storage must be maintained at or below -4 degrees F. Observation of the Sterling Unit nourishment refrigerator 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 · E2024-05-03 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
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, review of the facility's investigation, and review of the facility's policy, the facility failed to ensure alleged violations of abuse were thoroughly investigated for 5 of 11 sampled residents that were reviewed in 7 allegations of resident-to-resident abuse, Resident (R) 27, 168, 368, 94, and 87. The facility failed to provide documented evidence of an investigation in three facility-reported allegations of abuse. These investigations involved R27 and R168, that occurred on 06/30/2023; R368 and R94, that occurred on 07/11/2023; and R368 and R87, that occurred on 09/10/2023. The findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised 10/31/2022, revealed, as part of the identification process, the facility was responsible for taking all necessary actions as a result of the investigation, to include analyzing the occurrence to determine why it occurred, and the changes needed to prevent further occurrences. 1. Review of R27's admission…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-05-03 · tag F0688 — failed to keep residents mobile / prevent decline — patternProvide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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 documents and policy, the facility failed to ensure residents with limited range of motion (ROM) received appropriate treatment and services to increase ROM for 3 of 3 residents sampled for ROM (Resident (R) 1, 37 and 79). Multiple staff interviews revealed the facility currently had no restorative nursing program (RNP). The findings include: Review of the facility's policy titled, Restorative Nursing Programs, undated, revealed it [was] the policy of [the] facility to provide maintenance and restorative services designed to maintain or improve a resident's abilities to the highest practicable level. The RNP [referred] to nursing interventions that [promoted] the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively [focused] on achieving and maintaining optimal physical, mental, and psychosocial functioning. Nursing personnel [were] trained on basic, or maintenance nursing care…
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 before2024-05-03 · tag F0880 — failed to prevent and control infections — patternProvide 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, review of the Centers for Disease Control and Prevention (CDC) guidelines, review of the manufacturers' directions for use for the glucometer (blood glucose monitoring device) and disinfectant wipes, and review of the facility's policies, the facility failed to identify and correct problems related to infection prevention practices for 5 out of 57 sampled residents, Resident (R) 31, R37, R43, R49, and R318. Three additional observations of the Bluegrass Unit (BGU) revealed violations of infection control standards. 1. Observation of R37 and R43 revealed staff failed to clean the glucometer (shared equipment) before and after use according to the Environmental Protection Agency (EPA) registered disinfectant manufacturer's instructions. In addition, for both residents, appropriate hand hygiene was not performed. 2. Observation of R318 and R31 revealed staff failed to clean and disinfect a mechanical lift (shared equipment) after use on the residents. 3. Observation…
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 · D2024-05-03 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect 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 the facility's documents and policies, the facility failed to protect residents from abuse for 3 of 11 sampled residents investigated for abuse (Resident (R) 87, 94, and 101). On 07/11/2023, R368 struck R94 on the side of the head. On 09/10/2023, R168 kicked R87 in the leg. On 10/26/2023, R94 kicked R101 in the right knee. The findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, reviewed/revised on 10/31/2022, indicated it was the policy of [the] facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy defined Abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain…
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 · D2024-05-03 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policy, the facility failed to refer the resident for a level II pre-admission screening and resident review (PASARR) with a newly evident, serious mental illness for 1 of 1 residents sampled for PASARR review (Resident (R) 94). The findings include: Review of the facility's policy titled, Resident Assessment-Coordination with PASARR Program, dated 2023, revealed the facility coordinated assessments with the PASARR program to ensure individuals with a mental disorder received care and services in the most integrated setting appropriate for their needs. Further review revealed any resident who was readmitted to the facility following an inpatient psychiatric admission would be referred promptly to the state mental health authority for a level II review. Review of R94's admission Record revealed the facility admitted the resident on 03/10/2023 with diagnoses including metabolic encephalopathy (altered consciousness due to brain dysfunction), dementia…
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 before2024-05-03 · 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 the facility's documents and policies, the facility failed to develop and implement a comprehensive, person-centered care plan to meet a resident's medical, nursing, and psychosocial needs for 3 of 30 sampled residents (Residents (R) 11, 23, and 100). R100 had a care plan intervention for staff to follow physician's orders when providing care to the gastric tube insertion site. R100 developed an infection at the gastric tube insertion site; however, staff failed to implement the care plan intervention and follow the physician's orders for R100's gastric tube insertion site care. R23's care plan had interventions for the resident to wear a skin protective device and to keep fingernails trimmed; however, staff did not implement these interventions. R11 needed podiatry services; however, R11's care plan was not developed to include this intervention. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, dated 2023,…
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 · D2024-05-03 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility's policy, the facility failed to provide quality care according to the resident's plan of care for 1 of 3 residents sampled for skin care, Resident (R) 23. The findings include: Review of the facility's policy titled, Skin Integrity-Skin Tears, dated 2022, revealed the facility was responsible to intervene to protect residents from self-inflicted injury. Further review revealed facility staff members were responsible to modify the resident's plan of care for resident non-compliance. Review of R23's admission Record revealed the facility admitted the resident on 04/10/2019. Further review revealed R23's current diagnoses as of 05/01/2024 included peripheral vascular disease, type 2 diabetes, and psychotic disorder with delusions. Review of R23's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/08/2024, revealed the facility assessed R23 as severely cognitively impaired and unable to complete a Brief Interview…
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 · D2024-05-03 · tag F0687 — failed to care for feet properly — isolatedProvide appropriate foot care.
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, the facility failed to provide podiatry services for foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) for 1 of 5 sampled residents, Resident (R) 11. The findings include: Review of facility policy titled, Podiatry Services, undated, revealed residents received proper treatment and care within professional standards of practice to maintain mobility and good foot health. The policy stated residents requiring foot care who had complicating disease processes would be referred to qualified professionals including a Podiatrist. Continued review revealed foot disorders included nail disorders, and staff should refer any identified foot care needs to the Social Worker or designee. Further review revealed the Social Worker or designee would refer residents' services providing treatment in the facility or making and arranging…
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 · D2024-05-03 · tag F0693 — failed to provide proper feeding-tube care — isolatedEnsure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and review of the facility's policy, the facility failed to prevent complications of enteral feeding for 1 of 3 residents sampled for tube feeding care, Resident (R) 100. Observation on 05/02/2024 revealed the nurse failed to apply a bacterial ointment to R100's infected gastric tube insertion site as ordered by the physician. The findings include: Review of the facility's policy titled, Care and Treatment of Feeding Tubes, dated 2023, revealed the facility was to implement interventions to prevent complications of enteral feedings, including cleaning of the insertion site to prevent or resolve skin irritation and local infection. Review of R100's admission Record revealed the facility admitted the resident on 07/29/2023 with diagnoses including hemiplegia (paralysis of one side of the body) following cerebral infarction (stroke), dysphagia (impaired swallowing), and dysarthria (impaired speech caused by weak muscles). Review of R100's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/20/2024, revealed 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 · D2024-05-03 · tag F0887 — isolatedEducate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, review of the Centers for Medicaid and Medicare Services (CMS) document, and review of the facility's policy, the facility failed to maintain documentation of screening, education, offering, and current COVID-19 vaccination status for 2 of 3 sampled staff, Kentucky Medication Aide (KMA) 3, and Dietary Aide (DA) 1. This failure placed the residents and staff at increased risk for communicable diseases and healthcare-associated infections (HAI). The findings include: Review of the CMS's Center for Clinical Standards and Quality/Quality, Safety & Oversight Group's QSO-21-19-NH Memo, dated 05/01/2021, revealed Long-term Care facilities (LTC) must offer staff vaccination against COVID-19 when vaccine supplies were available to the facility. LTC's must screen staff prior to offering the vaccination for prior immunization, medical precautions, and contraindications to determine whether they were appropriate candidates for vaccination. Per the guidance, the vaccine might be offered and provided directly by the LTC facility or indirectly, such as through an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“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
$13,520 in federal fines across 1 penalty.
- $13,520 — penalty dated 2025-10-22
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.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
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.
This home reported $2.6M paid to related parties — landlords or management companies under common ownership — equal to about 19% 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 185242. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-06, 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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