Cycle 1
Health 2025-07-18 · Fire 2025-07-18
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Bardstown, KY
Bardstown Health & Rehabilitation
2-star overall rating with 2-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
120 Life Care Way, Bardstown, KY
(502) 348-4220
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
48
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lyon Healthcare
Operator or chain grouping
Approved since
1978-02-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.87
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.31
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.68
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
4.86
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
2.18
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.25
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
3.96
CMS adjusted total nurse staffing hours
Case-mix index
1.68
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,045
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
8.82
Composite VBP score used to determine payment impact.
Payment multiplier
0.9808
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.14% · Performance 21.96% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.41% · Performance 8.19% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.53
Baseline 73.26% · Performance 53.76% · Measure score 3.53 · Achievement 2.43 · Improvement 3.53
Adjusted total nurse staffing
0
Baseline 3.17 hours · Performance 3.01 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.24% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 148 · Observed rate 10.14% · Lower 95% interval 8.15% |
| Discharge to community | 52.68% |
50.57%
2.1 pts better
|
No Different than the National Rate · Eligible stays 126 · Observed rate 45.24% · Lower 95% interval 43.92% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 90 · Denominator 90 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 90 |
| Discharge self-care score | 36.36% |
53.69%
17.3 pts worse
|
Numerator 24 · Denominator 66 |
| Discharge mobility score | 25.76% |
50.94%
25.2 pts worse
|
Numerator 17 · Denominator 66 |
| Pressure ulcers or injuries, new or worsened | 7.78% |
2.29%
5.5 pts worse
|
Numerator 7 · Denominator 90 · Adjusted rate 5.54% |
| Healthcare-associated infections requiring hospitalization | 8.19% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 113 · Observed rate 8.85% · Lower 95% interval 5.11% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 103 |
| Staff flu vaccination coverage | 29.93% |
42%
12.1 pts worse
|
Numerator 41 · Denominator 137 |
| Discharge function score | 43.94% |
56.45%
12.5 pts worse
|
Numerator 29 · Denominator 66 |
| Transfer of health information to provider | 97.67% |
95.95%
1.7 pts better
|
Numerator 42 · Denominator 43 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 43.9% |
25.2%
18.7 pts better
|
Numerator 18 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.9
0.1 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 3.0 · Expected 3.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.2
0.8 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 2.0 · Expected 2.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
94.3%
4.5 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 98.7% · Q3 97.4% · Q4 100.0% · 4Q avg 98.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
96.2%
2.6 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.4% |
3.8%
1.6 pts worse
|
3.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 5.3% · Q3 7.7% · Q4 0.0% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 20.5% |
15.2%
5.3 pts worse
|
11.4%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 18.9% · Q3 16.1% · Q4 23.8% · 4Q avg 20.5% |
| Percentage of long-stay residents who lose too much weight | 13.8% |
6.7%
7.1 pts worse
|
5.4%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 13.2% · Q3 19.4% · Q4 11.1% · 4Q avg 13.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 38.9% |
29.6%
9.3 pts worse
|
19.6%
19.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.4% · Q2 40.3% · Q3 42.1% · Q4 40.0% · 4Q avg 38.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.2% |
17.6%
5.4 pts better
|
16.7%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 14.0% · Q3 10.3% · Q4 5.3% · 4Q avg 12.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.3% |
17.3%
3 pts worse
|
16.3%
4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.2% |
15.6%
2.4 pts better
|
14.9%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 9.4% · Q3 0.0% · Q4 5.1% · 4Q avg 13.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.7%
0.2 pts worse
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.8% |
19.8%
6 pts worse
|
19.8%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.3% · Q2 25.9% · Q3 26.1% · Q4 18.0% · 4Q avg 25.8% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
5.5%
0.6 pts better
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 4.7% · Q3 3.3% · Q4 2.7% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.3% |
83.8%
11.5 pts better
|
81.7%
13.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 93.2% · Q3 95.9% · 4Q avg 95.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.7% |
13.9%
4.8 pts worse
|
12.0%
6.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.7% · Observed 18.8% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.8%
0.1 pts better
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.5% · Q3 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.0% |
83.6%
1.4 pts better
|
79.7%
5.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.3% |
24.5%
8.2 pts better
|
23.9%
7.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.3% · Observed 17.2% · Expected 25.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-05-01 · Fire 2021-05-01
14 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-06-21 · Fire 2019-06-21
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-07-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-07-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-09-03
F · Potential for more than minimal harm
2025-03-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-23
E · Potential for more than minimal harm
2025-03-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-03-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-05-23
E · Potential for more than minimal harm
2021-05-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-05-28
E · Potential for more than minimal harm
2021-05-01
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-05-28
D · Potential for more than minimal harm
2021-05-01
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2021-05-28
D · Potential for more than minimal harm
2021-05-01
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-05-28
D · Potential for more than minimal harm
2021-05-01
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2021-05-28
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-18
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-07-18
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-07-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-09-03
E · Potential for more than minimal harm
2021-05-01
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2021-05-28
E · Potential for more than minimal harm
2021-05-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-05-28
D · Potential for more than minimal harm
2021-05-01
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2021-05-28
D · Potential for more than minimal harm
2021-05-01
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2021-05-28
D · Potential for more than minimal harm
2021-05-01
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2021-05-28
D · Potential for more than minimal harm
2021-05-01
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2021-05-28
D · Potential for more than minimal harm
2021-05-01
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2021-05-28
D · Potential for more than minimal harm
2021-05-01
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-05-28
D · Potential for more than minimal harm
2021-05-01
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2021-05-28
D · Potential for more than minimal harm
2021-05-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-05-28
D · Potential for more than minimal harm
2021-05-01
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-05-28
D · Potential for more than minimal harm
2021-05-01
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2021-05-28
D · Potential for more than minimal harm
2021-05-01
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-05-28
D · Potential for more than minimal harm
2021-05-01
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-05-28
F · Potential for more than minimal harm
2019-06-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-08-21
E · Potential for more than minimal harm
2019-06-21
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2019-08-21
D · Potential for more than minimal harm
2019-06-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-08-21
D · Potential for more than minimal harm
2019-06-21
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-08-21
D · Potential for more than minimal harm
2019-06-21
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-08-21
D · Potential for more than minimal harm
2019-06-21
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2019-08-21
D · Potential for more than minimal harm
2019-06-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-08-21
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
Signature Healthcare At Colonial Rehab & Wellness
Bardstown, KY
1-star overall rating with 1-star inspections with $67,987 in total fines with 3 fire-safety deficiencies in the latest cycle
#2
Loretto Living Center At Loretto Motherhouse, Inc
Nerinx, KY
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
#3
Sansbury Care Center
Saint Catharine, KY
5-star overall rating with 4-star inspections with $5,346 in total fines with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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