Bourbon Heights Nursing Home

Location & what’s nearby

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

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

47.2% 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 28 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Therapy staffing: this home’s payroll records show 0.40 therapist hours per resident per day in 2026Q1 — more than 69% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 20% 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.

Staffing

How full it usually is: this home is certified for 99 beds and averages 78.8 residents a day — about 80% occupied, or roughly 20 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.74 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.60 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.26 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 4.15 hrs/resident/day on weekends vs 4.98 on weekdays — 17% thinner on weekends. RN hours go from 0.62 to 0.54 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 58% is well above the national median of 45%. 1 administrator has left in the past year.

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

Inspection trend

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.

29 citations, most serious first. The 21 most serious are shown; the remaining 8 are one tap away and print in full.

• Immediate jeopardy · L2024-11-22 · tag F0835 — failed to run the facility competently — widespread
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, review of the Director of Nursing Services (DON) and Administrator's Job Descriptions, review of the facility's employee agreement for the Administrator, review of the Division of Epidemiology and Health Planning's (DEHP) Findings and Recommendations, and review of the facility's policies, the facility failed to ensure it was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for the total census of 74 residents. On 05/28/2024, Legionella pneumophila Serogroup 1 Strain (SG1) and Legionella pneumophila Serogroup 2 Strain (SG2-15) were identified at uncontrolled growth levels in the Unit 3 shower. Review of the Division of Epidemiology and Health Planning's (DEHP) Findings and Recommendations, dated 07/26/2024, revealed the DEHP recommended steps to prevent future outbreaks or occurrences of legionellosis. However, the facility's administration failed…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · L2024-11-22 · tag F0837 — widespread
  Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
  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 Division of Epidemiology and Health Planning's (DEHP) Findings and Recommendations, review of the facility's Bylaws, and review of the facility's policies, it was determined the facility's Governing Body failed to ensure the facility's policies were implemented regarding the management and operation of the facility for the total census of 74 residents. On 04/04/2024, Immediate Jeopardy (IJ) was identified in the area of F880 (Infection Control) during an Abbreviated Partial Extended Survey with an exit date of 04/05/2024. The facility submitted a Plan of Correction (POC) for deficiencies, cited on 04/05/2024, alleging substantial compliance on 05/20/2024. However, during the Recertification/Abbreviated Survey concluded on 11/22/2024, it was determined the facility failed to maintain substantial compliance. The facility failed to implement their plan of correction as described in the documents issued to the State Survey Agency, which included to follow 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · L2024-11-22 · tag F0867 — failed to act on quality-improvement findings — widespread
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, review of the facility's plan of correction from the 04/05/2024 survey, and review of the facility's policy, the facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) Program that developed and implemented appropriate plans of action to correct quality deficiencies. Quality deficiencies were evidenced by the facility's failure to establish and maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases. The facility was cited for infection control related to legionellosis and their water management system during the 04/05/2024 survey, and the facility submitted a plan of correction to address the deficiency. However, the facility failed to follow the plan of correction to complete a Water Infection Control Risk Assessment (WICRA) and develop a Water Management Plan (WMP). On 05/28/2024,…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Lcited before2024-11-22 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility's documentation and policies, 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 the total census of 74 residents. During the Abbreviated/Partial Extended Survey that concluded on 04/05/2024, Immediate Jeopardy was identified in the area of F880 (Infection Control), with the highest scope and severity (S/S) of an L. The facility alleged substantial compliance on 05/20/2024, however; failed to maintain substantial compliance. Legionella pneumophila SG1 and Legionella pneumophila SG2-15 were identified at uncontrolled growth levels in the Unit 3 shower on 05/28/2024. Review of the state's Division of Epidemiology and Health Planning's (DEHP) Findings and Recommendations, dated 07/26/2024, revealed DEHP made recommendations…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-11-22 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately 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 policy, it was determined the facility failed to notify the resident's physician of a significant change in the resident's physical status for one of 26 sampled residents, (Resident (R)76). R76 sustained an unwitnessed fall on 05/16/2024 at 1:15 PM, and Registered Nurse (RN) 2 (an agency nurse) notified the Nurse Practitioner (NP), who advised monitoring the resident, with no new orders given. RN2 noted R76 had prolonged elevated blood pressure readings, with systolic readings between 180 and 190 until 7:00 PM. However, RN2 failed to inform the NP of R76's continued elevated blood pressure readings. On 05/17/2024, R76's blood pressure continued to remain elevated, and the resident presented a mental status change which included: lethargy, confusion, and incoherent speech. However, RN2 failed to document the mental status changes observed and failed to notify the physician/NP of R76's worsening physical condition. R76's family arrived to visit the resident at 6:00 PM on 05/17/2024 and expressed their concerns about R76.…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Jcited before2024-11-22 · tag F0656 — failed to write and follow a full care plan — isolated
  Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and review of the facility's policies, the facility failed to have an effective system in place to ensure residents' Comprehensive Care Plans (CCP's) interventions were implemented when a change of condition occurred for one of 26 sampled residents, (Resident (R)76). Review of the facility's CCP developed for R76 revealed the resident was care planned for hypertension to include interventions to monitor, document, and report to the medical provider any signs and symptoms of headache, confusion, and lethargy. R76 sustained an unwitnessed fall on 05/16/2024 at 1:15 PM, and Registered Nurse (RN) 2 notified the Nurse Practitioner (NP) who advised monitoring the resident. RN2 documented normal neurological (neuro) checks for R76. However, the resident experienced prolonged elevated blood pressures (B/P's) with systolic readings between 180 and 190 (The resident's baseline systolic readings were 120 to 130) until 7:00 PM. R76 also verbalized a compliant of a headache to staff. However, RN2 failed to follow the care plan to monitor, document,…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2024-11-22 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide 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, and record review the facility failed to promptly identify and intervene for a change in the resident's condition and ensure the resident received prompt assessment and emergency care for one of 26 sampled residents, (Resident (R)76). R76 sustained an unwitnessed fall on 05/16/2024 at 1:15 PM and Registered Nurse (RN) 2 (an agency nurse) notified the Nurse Practitioner (NP) who ordered continued monitoring of the resident, with no additional orders. RN2's assessments noted R76's neurological (neuro) checks were within normal limits (WNL) and the resident was experiencing prolonged elevated blood pressure (B/P), with systolic readings consistently between 180 and 190 until 7:00 PM. However, RN2 failed to notify the NP about R76's elevated B/P. On 05/17/2024 at 8:00 AM and 4:00 PM, R76's B/P remained elevated and at 4:00 PM, the resident was also exhibiting a change in mental status, to include lethargy and incoherent speech. However, RN2 failed to document those findings and did…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · Lcited before2024-04-05 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of the facility's policies, 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. The facility's census was 76. The facility failed to implement the state's Division of Epidemiology and Health Planning's (DEHP) recommendation as communicated by the Local Health Department (LHD) on 03/21/2024, to use faucet filters (or bottled water) until the facility completed further testing to prevent and control the spread of a water-borne infection with legionella. Staff interviews revealed they unaware of water contamination concerns and continued to use the sink faucets in residents' rooms for brushing the resident's teeth, hygiene, and drinking water, as well as hand hygiene for staff. The facility's failure to establish and maintain an infection…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-11-22 · tag F0655 — isolated
  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  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 facility policy review, the facility failed to develop and implement a baseline care plan for new residents that included instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care for one of 26 sampled residents (Resident (R)425). R425 required hemodialysis treatments that included parameters for the resident's vital signs and had a known history of falls. However, the facility failed to implement a baseline care plan upon R425's admission to address his hemodialysis needs and risk for falls. Refer to F689 and F698 The findings include: Review of the facility's policy titled, Care Plan Development in the HER Policy and Procedure, dated 11/2016, revealed it was the policy of the facility that the care plan was a living document that was started upon admission. Per review, the care plan was started upon a resident's admission from information gathered from the resident, family, admission assessments…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2024-11-22 · tag F0657 — failed to keep the care plan current — isolated
  Develop 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 interview, record review, and review of the facility's policy, the facility failed to review and revise the comprehensive care plan (CCP) for one of 26 sampled residents (Resident (R)76). R76 fell on [DATE], and after having a change in mental status was transferred to the hospital on [DATE], where she was diagnosed with a transient ischemic attack (a brief stroke-like attack). R76 returned to the facility on [DATE]. R76's family requested the resident remain in her room to rest after her hospitalization. However, staff on duty failed to update the CCP to include interventions aimed at preventing future falls or to incorporate the family's request for the resident to rest in her room. R76 sustained another fall on 05/19/2024, resulting in a fracture of the intertrochanteric region of her hip. Refer to F689 The findings include: Review of the facility's policy titled, Care Plan Development in the EHR [electronic health record] Policy and Procedure, undated, revealed the facility must create and implement…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2024-11-22 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policies, the facility failed to ensure the residents' environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for one of 26 sampled residents (Resident (R)76). 1. R76 sustained an unwitnessed fall on 05/16/2024 while ambulating from the bathroom to the bed. The resident had a change in mental status and was taken to the local hospital where she was admitted with dysarthria (a speech disorder caused by weak or hard-to-control muscles in the mouth, face or upper respiratory system), prolonged elevated blood pressure, and was also diagnosed with a transient ischemic attack (TIA) (a brief stroke-like attack). The resident returned to the facility from the hospital on [DATE]. Further, after R76's return from the hospital, the family requested that the resident remained in her room to rest after her hospitalization. Despite this, staff…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2026-02-19 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of Droplet Precautions signage, review of the Centers for Disease Control and Prevention (CDC) guidelines, and review of the facility's policies, 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 and to implement interventions to protect facility residents. Observations on 02/17/2026 and 02/18/2026 revealed staff cleaned a glucometer without donning (putting on) gloves; staff failed to sanitize blood pressure cuffs before using on residents and failed to place them on barriers while contaminated; staff failed to wear appropriate personal protective equipment (PPE) in a resident room designated with Droplet Precautions signage; and staff failed to remove a mask after exiting a room designated with Droplet Precautions signage, for 6 of 16 residents sampled 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-02-19 · tag F0847 — pattern
  Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on review of the facility's document and interview, the facility failed to ensure its binding arbitration agreement contained appropriate verbiage granting residents the right to rescind the agreement within 30 days of signing it. This deficient practice had the potential to affect 56 of the facility's current census of 76 residents.Review of a facility provided list of residents who had signed binding arbitration agreements revealed 56 residents had signed binding arbitration agreements. Review of the facility's document Agreement to Resolve Disputes by Mediation and Binding Arbitration, not dated, did not include the explicit verbiage granting residents or representatives the right to rescind the agreement within 30 calendar days of signing it.In an interview with the Admissions/Marketing Director (A/M) on 02/18/2026 at 8:43 AM, she stated she had been in that role with the facility for approximately one year, although she had been in the Admissions/Marketing role for 20 years. She stated the binding arbitration agreement had been in use when she took the A/M position. She…

  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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2026-02-19 · tag F0912 — pattern
  Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
  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 and interview, the facility failed to ensure resident rooms measured at least 80 square feet per resident in multiple occupancy rooms. Observation of eight dual-occupancy rooms (two residents per room) for Rooms 127, 128, 129, 130, 132, 133, 135 and 138, revealed each room measured less than the required square footage, with rooms measuring anywhere from approximately 17 square feet short (Rooms 127, 128, 129, 130) to approximately 26 square feet short (room [ROOM NUMBER]). The findings include:Observation with the Maintenance Director (MD) and the Maintenance Assistant (MA) on 02/18/2026 at 3:00 PM revealed Rooms 127, 128, 129, and 130 had the same layout, and measured 142.79 square feet in diameter, 17.21 square feet below the required 160 square feet for a dual occupancy room, or 80 square feet per resident. Observation of room [ROOM NUMBER] with the MD and the MA on 02/18/2026 at 3:04 PM revealed the room to measure 133.92 square feet, 26.08 square feet below the requirement for a dual…

  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.

  Environmental Deficiencies · Deficient, Provider has no plan of correction
• Potential for harm · Dcited before2026-02-19 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and review of the facility's policy, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 15 residents sampled. The resident preferred to remain anonymous.Interview with 1 of 15 sampled residents who wished to remain anonymous stated their room was too small.Refer to F912The findings include:Review of facility's policy titled, Resident Rights, no date given, revealed the facility must protect and promote the rights of each resident to ensure a dignified existence and self-determination; and the resident had a right to be treated with dignity and respect. Further review revealed the resident rights included to retain and use personal possessions including furnishings and clothing as long as it did not infringe upon the rights, health, or safety of other residents. Review of the anonymous resident's Face Sheet revealed the facility admitted…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2024-11-22 · tag F0550 — failed to protect resident dignity and rights — widespread
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policy, the facility failed to treat each resident with respect and dignity, and care for each resident in a manner and environment that promoted maintenance or enhancement of his/her quality of life, recognizing each resident's individuality for the total census of 74 residents, which included (Resident (R)3, R6, R9, R21, R41, R55, and R67). On 08/29/2024, and 09/04/2024, the sample result for the Unit 2 shower showed legionella non-pneumophila at poorly controlled growth levels. Staff interviews revealed the facility failed to provide showers for residents starting in early September 2024, due to the showers on Unit 1, Unit 2, and Unit 3 being closed. During that timeframe residents were only offered bed baths. Recommendations were made by the independent water systems company (IWSC) and the certified water safety and management expert (CLWSE) to bring in portable showers as a temporary measure in order for residents to have the opportunity to…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2024-11-22 · tag F0726 — failed to have competent, trained nursing staff — widespread
  Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
  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, poilcy review, and the facility assessment the facility failed to ensure the licensed nurses and other nursing personnel had the knowledge, competencies and skill sets to provide care and respond to each resident's individualized needs as identified in his/her assessment and care plan. In interview agency staff stated they had not received training or education prior to being assigned to residents' care. The findings include: Review of the facility's policy titled, Resident Rights, undated, revealed residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety to the resident or other residents. Review of the facility document titled, Facility Assessment Tool: [Facility Name], Inc. undated, revealed there was no accommodation for agency staffing in the assessment. Per review of the Assessment, in the section titled, Table 3.1: Staff Competencies 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2024-11-22 · tag F0838 — failed to assess facility resources and resident needs — widespread
  Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
  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 facility documentation and it 2024 Facility Assessment, it was determined the facility failed to conduct and document a facility-wide assessment to determine the necessary resources for addressing the the ongoing legionella bacterial contamination in the facility's water system. Additionally, the facility failed to address the volume of agency staffing in its assessment to evaluate its resident population and identify resources essential for provision of the necessary care and services of those residents during day-to-day operations and emergencies. Refer to F880 and F726 The findings include: Review of the facility document titled, Facility Assessment Tool: [Facility Name], Inc., dated 06/01/2024, revealed under the Infection Control Risk Assessment section a requirement for a discussion on how the facility evaluated the effectiveness of its infection prevention and control program in identifying, reporting, investigating, and controlling infections 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.

  Administration Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-11-22 · tag F0678 — failed to provide CPR when needed — pattern
  Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
  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 and review of facility policy, the facility failed to have systems in place to ensure there were an adequate number of staff always present who were properly trained and/or certified in Cardiopulmonary Resuscitation (CPR) for Healthcare Providers to be able to provide CPR until emergency medical services arrived. The deficient practice had the potential to affect all facility residents who required CPR. The findings include: Review of the facility's policy titled, CPR Certification, dated 01/2020, revealed all licensed nurses were responsible for obtaining a Basic Life Support (BLS) CPR certification from an accredited licensing agency. Per review, all Kentucky Medication Aides (KMA) were also responsible for obtaining a Basic Life Support (BLS) CPR certification from an accredited licensing agency. Review of the facility's list of all its nurses and KMA's with CPR certification, provided by the Interim Director of Nursing (DON), revealed eight nurses currently employed had expired CPR…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-11-22 · tag F0804 — failed to serve food at safe, palatable temperature — pattern
  Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and review of facility policy, the facility failed to ensure each resident received food and drinks which were palatable, attractive, and at a safe and appetizing temperature for five of nine sampled residents reviewed for food temperatures (Residents (R)68, R29, R9, R65, and R58). During resident council, residents expressed concerns of their food being served cold when the aides passed their trays. Observation of the lunch meal on 11/20/2024, revealed the beef and noodle entree and vegetable medley were not at an appetizing and acceptable temperature. The findings include: Review of the facility's policy titled, Food Temperatures, dated 2003-2004, revealed the appropriate serving temperature (temp) of hot foods was for the food to be over 140 degrees (140°) Fahrenheit (F) for hot foods. Review of the facility's Room Test Tray Evaluation Form, undated, noted the acceptable point of service (POS) temp for hot foods was 135° to 160° F. Review of the facility's form titled, Food Temperatures, undated, revealed the POS temp for hot foods…

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

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-11-22 · tag F0582 — isolated
  Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
  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 and record review, it was determined the facility failed to ensure residents were notified of changes to services covered by Medicare and/or Medicaid as soon as possible for one of three sampled residents reviewed for appeal writes (Resident (R)38). R38 received therapeutic services; however, the facility failed to inform the resident in writing of the end date to services or of their right to appeal. The findings include: During the task of Beneficiary Notification Review, the State Survey Agency (SSA) determined for the three residents selected, there was no documented evidence one of the residents received form CMS 10055 (Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage) or form CMS 10123 (Notice of Medicare Non-Coverage). Continued review revealed, of the three residents, one resident was voluntarily discharged from services as family elected hospice services (R125). Per review, a second resident opted to discharge from services and returned home with home health with…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$57,841 in federal fines across 2 penalties. 2 Medicare payment denials on record.

• $41,040 — penalty dated 2024-11-22
• $16,801 — penalty dated 2024-04-05
• Medicare payment denial — starting 2024-12-25 for 31 days
• Medicare payment denial — starting 2024-05-04 for 16 days

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

CMS files one row per role, so the 11 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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.

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