Madonna Manor

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.

61.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 103 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 52.7% 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 74 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 0.44 therapist hours per resident per day in 2026Q1 — more than 75% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 16% 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 60 beds and averages 54.5 residents a day — about 91% occupied, or roughly 6 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 6.85 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.94 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 4.83 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 6.37 hrs/resident/day on weekends vs 7.04 on weekdays — 9% thinner on weekends. RN hours go from 1.08 to 0.62 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 63% is well above the national median of 45%.

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

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

21 citations, most serious first. The 16 most serious are shown; the remaining 5 are one tap away and print in full.

• Immediate jeopardy · J2025-08-23 · 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, review of the website www.weather.gov, and review of the facility's policies, the facility failed to have an effective system in place to ensure each resident received the electronic monitoring devices to prevent unsafe wandering and elopement, for 1 of 18 sampled residents, Resident (R) 1.Review of R1's Investigation Report revealed R1 was found by State Tested Nurse Aide (STNA) 2 outside the building, approximately 84 feet from the employee entrance/exit, on 08/07/2025 at 11:10 PM as she was getting out of her car from the back parking lot of Household B. Per the report, STNA2 brought R1, who appeared to be confused and was unstable with ambulation, back into the facility to get warm. During interviews conducted with facility staff who were on duty during the time of the 08/07/2025 elopement, they stated they had last seen the resident at approximately 9:30 PM and were unaware R1 left the building unsupervised until they received notice from Registered Nurse (RN) 1.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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2025-01-03 · 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 2 of 11 sampled residents, Resident (R) 2 and R3. 1. On 12/01/2024, in the early hours of the morning, R3 was observed by Registered Nurse (RN) 2 to have a significant change in mental status. Despite this critical finding, RN2 failed to notify the physician about the resident's condition. At 7:00 AM, during the shift change report, RN2 relayed to Licensed Practical Nurse (LPN) 1 that the resident's mental status had deviated from the baseline during the night. However, neither nurse assessed R3 or notified the physician of his change in mental status. At approximately 11:30 AM, R3's family alerted LPN1 that R3 was febrile, unresponsive, and had tremors. The family requested the nurse to call emergency medical services (EMS) for transfer to the local emergency department (ED). R3 presented to the ED in an altered mental status, septic, and in atrial fibrillation with rapid…

  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 · J2025-01-03 · 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

  Based on interview, record review, and review of the facility's policy, the facility failed to develop and implement a baseline care plan within 48 hours for each resident that included instructions needed to provide effective and person-centered care of the resident to meet professional standards of quality care for 2 of 11 sampled residents, Resident (R) 2 and R3. 1. On 11/26/2024, the facility admitted R3 with an intrathecal (the space between the spinal cord and the membranes that protect it) pain pump infection, which was being treated with intravenous (IV) antibiotic therapy via a peripherally inserted central catheter (PICC) line. The facility failed to develop a person centered baseline care plan with interventions to address R3's infection, antibiotic therapy, care of the PICC line, or physician notification for worsening condition. Immediate Jeopardy (IJ) was identified on 12/20/2024 and was determined to exist on 11/26/2024, in the area of 42 CFR §483.21 Baseline Care Plan, F655 at a Scope and Severity (S/S) of a J. The facility was notified of the IJ on 12/20/2024 at…

  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 · J2025-01-03 · 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 interview, record review, and review of the facility's policy, the facility failed to promptly identify and intervene with a significant change in a resident's condition, for the resident to receive treatment and care in accordance with professional standards of practice for 1 of 11 sampled residents, Resident (R) 3. R3 was admitted to the facility on [DATE] with diagnoses to include post-surgical infection of the intrathecal (the space between the spinal cord and the membranes that protect it) pain pump. The resident was to receive two weeks of intravenous (IV) antibiotic therapy by a peripherally inserted central catheter (PICC) line. However, the resident did not receive four of those ordered doses. In addition, the MAR revealed the physician ordered metronidazole (an antibiotic) to be administered orally every eight hours, but R3 did not receive five of those doses. On 12/01/2024, in the early hours of the morning, R3 was observed by Registered Nurse (RN) 2 to have a significant change in mental…

  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 · J2025-01-03 · tag F0760 — failed to prevent significant medication errors — isolated
  Ensure that residents are free from significant medication errors.
  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 have an effective system in place to ensure residents were free from significant medication errors for 1 of 2 sampled residents receiving intravenous (IV) antibiotic therapy, Resident (R) 3. On 11/26/2024, the facility admitted R3 with diagnoses to include post laminectomy syndrome (chronic pain following back surgery; a laminectomy was removing part or all of the bony arch that covered the spinal cord) and post-surgical infection of the intrathecal (the space between the spinal cord and the membranes that protect it) pain pump. The resident was scheduled to receive two weeks of intravenous (IV) antibiotic therapy while at the facility. Review of R3's Medication Administration Record [MAR] revealed the physician had ordered cefepime (an antibiotic given for infection) to be administered IV twice daily, but he did not receive four of those ordered doses. In addition, the MAR revealed the physician ordered metronidazole…

  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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2025-01-03 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review, and review of the facility's policies, the facility failed to provide services to prevent pressure ulcers for 1 of 11 sampled residents, Resident (R) 2. On 10/18/2024 an unstageable wound to R2's left bottom heel was found by Physical Therapy (PT) staff. The nursing staff was notified; however, they failed to put interventions in place to care for the wound and prevent further worsening. In addition, the facility failed to include interventions to address R2's need to ensure pressure off-loading boots were on the resident and to off-load the wound while in the bed or up in the wheelchair. The findings include: Review of the facility's policy titled, Pressure Injury Prevention Guidelines, revised 11/23/2022, revealed measures would be taken to prevent avoidable pressure injuries and to promote the healing of existing ones. Per the policy, the facility would implement evidence-based interventions for all residents assessed as being at risk or who currently had a pressure injury. The policy stated these interventions would be resident-centered 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.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2025-12-05 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and review of the facility's policies, the facility failed to store and prepare foods under sanitary conditions. Observations on 09/30/2025, 10/01/2025, and 12/03/2025 included cleaning cloths lying on the counter and not in the sanitizer bucket, trash cans without lids in the food production area, and foods in the dry storage area not labeled, dated, and expired. This deficient practice had the potential to affect all 53 current residents.The findings include:Review of the facility's policy titled, Food Safety Guidelines, not dated, revealed cross-contamination could be biological, chemical, and physical.Review of the facility's policy titled, Food Preparation, not dated, revealed wiping cloth buckets should be assigned an area, stored off the floor and away from food and food contact surfaces. Per the policy, wiping cloths shall be stored in sanitizer solution off the floor and away from food and food contact surfaces, and wiping cloths shall be stored in sanitizer solution when not in-use. The policy stated food products shall be labeled and must…

  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 · Dcited before2025-12-05 · tag F0880 — failed to prevent and control infections — isolated
  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 a disinfectant label, and review of the facility's policies, the facility failed to 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 by ensuring staff involved in direct resident contact followed hand hygiene procedures and wore required personal protective equipment (PPE) for 1 of 16 sampled residents, Resident (R) 20. In addition, the facility failed to ensure a barrier was used to protect an enhanced barrier precautions (EBP) supply cart from a blood pressure cuff that had not been sanitized.The findings include:Review of the facility's policy titled, Infection Prevention and Control Program, dated 08/30/2022, last revised date 10/07/2025, revealed the program was designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-02-27 · tag F0604 — failed to not use physical restraints improperly — isolated
  Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
  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 policies, the facility failed to ensure each resident had the right to be free from restraint for 1 of 5 sampled residents, Resident (R) 15. On 01/13/2025 at approximately 2:00 PM, a Dining Aide (DA) 1 tied a washcloth around one wheel of R15's wheelchair. Activity Assistant 2 saw R15 on the floor around 3:00 PM. At that time, Activity Assistant 2 notified State Trained Nurse Aide/Kentucky Medical Aide (STNA/KMA) 14 who was in the hall and STNA15. The facility provided an acceptable Plan of Correction (POC) on 01/31/2025 alleging past noncompliance. The State Survey Agency (SSA) survey team validated the deficient practice was corrected on 02/01/2025, following the facility's implementation of the acceptable POC and before the start of the survey. The findings include: Review of the facility's policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, effective 10/24/2022 and reviewed 02/26/2025, revealed staff was to immediately report all allegations of abuse/neglect/exploitation or…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Potential for harm · D2025-02-27 · tag F0607 — failed to have anti-abuse policies — isolated
  Develop and implement policies and procedures to prevent abuse, neglect, and theft.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review, and review of the facility's policy, the facility failed to implement the abuse policy for 1 of 5 sampled residents, Resident (R) 15. A Dining Aide (DA) 1 tied a washcloth around one wheel of R15's wheelchair around 2:00 PM on 01/13/2025. State Trained Nurse Aide (STNA) 13 witnessed DA1 tie the washcloth to the wheel of R15's wheelchair, but failed to report the incident, and R15 fell from her wheelchair. The facility provided an acceptable Plan of Correction (POC) on 01/31/2025 alleging past noncompliance. The State Survey Agency (SSA) survey team validated the deficient practice was corrected on 02/01/2025, following the facility's implementation of the acceptable POC and before the start of the survey. The findings include: Review of the facility's Abuse policy titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation, effective 10/24/2022, revealed the facility reported all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property. Per the policy,…

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

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
• Potential for harm · Ecited before2025-01-03 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, review of the manufacturer's instructions for use, 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 the development and transmission of communicable diseases and infections for 2 of 11 sampled residents, Residents (R) 4 and R8. 1. Observation on 12/12/2024 of R4's room revealed the resident was under contact isolation precautions. However, staff was observed in the room without wearing the appropriate personal protective equipment (PPE). Further observation on 12/12/2024 revealed another staff member entered R4's room and did not don (put on) PPE. 2. Observation and interview on 12/12/2024 with Licensed Practical Nurse (LPN) 1 revealed she carried a contaminated glucometer (blood sugar measuring device), without wearing gloves,…

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

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-03 · tag F0583 — failed to protect personal privacy — isolated
  Keep residents' personal and medical records private and confidential.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, record review, and facility policy review, the facility failed to ensure the resident's right to privacy was honored for 1 of 11 sampled residents, Resident (R) 8. On 12/18/2024, Licensed Practical Nurse (LPN) 1 lifted R8's shirt and exposed her abdomen while she administered an insulin injection to the resident. R8 was seated at a dining table with three other residents eating lunch. The findings include: Review of the facility's policy titled, Resident Rights, dated 10/24/2022, revealed the resident had a right to be treated with respect and dignity. Further review revealed the resident had a right to personal privacy and confidentiality to include personal privacy for medical treatment. Review of R8's Face Sheet, located in the resident's electronic medical record (EMR), revealed the facility admitted the resident on 11/28/2024 with diagnoses to include left hemiplegia and hemiparesis following cerebral infarction (stroke), type 2 diabetes mellitus, and chronic obstructive pulmonary disease (COPD). Review of R8's admission Minimum Data Set [MDS],…

  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 · D2025-01-03 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review, and facility policy review, the facility failed to ensure drugs and biologicals were stored according to professional standards for 1 of 3 medication carts where an opened pharmacy delivery tote with medications was left unattended. The findings include: Review of the facility's policy titled, Storage of Medications, undated, revealed drugs and biologicals stored in the facility were kept in locked compartments, accessible only to authorized personnel. According to the policy, nursing staff was responsible for managing medication storage. Per the policy, compartments containing drugs and biologicals must be locked when not in use, and any unlocked medications should not be left unattended. Observation of a medication cart in the Household B Hall on 12/12/2024 at 10:31 AM, revealed an opened pharmacy delivery tote full of medications. The delivery tote was left opened, unsecured, and unattended out in the open as residents and staff walked by. The tote contained two boxes of multiple single dose albuterol (bronchodilator) inhalation solution packets…

  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.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-08-23 · 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 interview, record review, and review of the facility's policy, the facility failed to ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promoted the maintenance or enhancement of his/her quality of life. The facility failed to ensure residents had a right to communicate with and had access to persons and services inside and outside the facility for 2 of 22 sampled and supplemental residents, Resident (R) 7 and R10. R7's representative and R10's representative stated they were unsuccessful when they attempted multiple times to communicate with the facility via telephone. The findings include: Review of the facility's policy titled, Resident Rights, dated 10/24/2022, revealed the resident had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 1. Review of R7's admission Record revealed the facility admitted the resident on 08/08/2013 with diagnoses of vascular dementia, hereditary and idiopathic neuropathy, and…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-23 · tag F0552 — isolated
  Ensure that residents are fully informed and understand their health status, care and treatments.
  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 policies, the facility failed to ensure each resident had the right to be informed of and participate in his or her treatment for 1 of 22 sampled and supplemental residents, Resident (R) 10. Staff refused to administer a COVID-19 test to R10 when requested by the resident. The findings include: Review of the facility's policy titled, Resident Rights, dated 10/24/2022, revealed the resident had the right to be informed of, and participate in, his or her treatment, including the right to request, refuse, and/or discontinue treatment. Review of the facility's policy titled, Coronavirus Testing, revised 09/26/2022, revealed anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test as soon as possible. Further review revealed the facility would obtain an order for COVID-19 testing from the physician, physician assistant, nurse practitioner, or clinical nurse specialist to provide or obtain laboratory services for a resident. Additional review revealed the facility would…

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

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-23 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
  Develop and implement policies and procedures for flu and pneumonia vaccinations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review, and review of the facility's policy, the facility failed to ensure that the resident's medical record included documentation that indicated the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal for 1 of 5 sampled residents, Resident (R) 43. A review of R43's immunization record revealed the absence of documentation confirming the administration or refusal of the influenza vaccine for 2023-2024. The findings include: Review of the facility's policy titled, Infection Prevention and Control Program, dated 10/24/2022, revealed residents would be offered the influenza vaccine each year between October 1 and March 31. Further review revealed documentation would reflect the education provided and details regarding whether the resident received the immunization. Review of R43's admission Record revealed the facility admitted the resident on 11/19/2023 with diagnoses of chronic obstructive pulmonary disease (COPD) and Alzheimer's disease. Review of R43's, Minimum…

  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

“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

$181,278 in federal fines across 2 penalties.

• $19,145 — penalty dated 2025-08-23
• $162,133 — penalty dated 2025-01-03

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to COMMONSPIRIT HEALTH — 18 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 82 rows in the source record cover these 42 parties — each is shown once here with every role it holds. Nothing is omitted.

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

Follow the money — this home’s finances

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

This home reported $856K paid to related parties (affiliated landlords or management companies) in its most recent 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 2024. 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, FY2024). 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