Cycle 1
Health 2025-05-08 · Fire 2025-05-08
3 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Beaver Dam, KY
Beaver Dam Nursing & Rehab Center, Inc
3-star overall rating with 3-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1595 S Us Highway 231, Beaver Dam, KY
(270) 274-9646
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
58
Certified beds
Average residents
56
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Providence Health Group
Operator or chain grouping
Approved since
1992-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
2 facilities
Chain averages 4 overall / 4 health / 3 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
0.53
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.62
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
4.02
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.54
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
3.94
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,153
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.23
Composite VBP score used to determine payment impact.
Payment multiplier
0.9905
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
0.53
Baseline 6.79% · Performance 7.67% · Measure score 0.53 · Achievement 0.53 · Improvement 0
Total nurse turnover
7.12
Baseline 77.14% · Performance 37.29% · Measure score 7.12 · Achievement 6.46 · Improvement 7.12
Adjusted total nurse staffing
3.51
Baseline 3.52 hours · Performance 4.08 hours · Measure score 3.51 · Achievement 3.51 · Improvement 1.97
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.7% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 48 · Observed rate 14.58% · Lower 95% interval 8.01% |
| Discharge to community | 38.24% |
50.57%
12.3 pts worse
|
No Different than the National Rate · Eligible stays 33 · Observed rate 30.3% · Lower 95% interval 27.45% |
| Medicare spending per beneficiary | 1.42 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 33 · Denominator 33 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 33 |
| Discharge self-care score | 42.31% |
53.69%
11.4 pts worse
|
Numerator 11 · Denominator 26 |
| Discharge mobility score | 53.85% |
50.94%
2.9 pts better
|
Numerator 14 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 6.06% |
2.29%
3.8 pts worse
|
Numerator 2 · Denominator 33 · Adjusted rate 5.13% |
| Healthcare-associated infections requiring hospitalization | 7.68% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 33 · Observed rate 9.09% · Lower 95% interval 3.77% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 53.85% |
56.45%
2.6 pts worse
|
Numerator 14 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
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 1.7 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.5 |
2.2
1.3 pts worse
|
1.8
1.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 3.3 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
94.3%
5.2 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.1% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.2%
3.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.9% |
3.8%
3.1 pts worse
|
3.3%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 5.8% · Q3 8.5% · Q4 8.0% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
15.2%
14.7 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 7.9% |
6.7%
1.2 pts worse
|
5.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 8.7% · Q3 7.5% · Q4 4.7% · 4Q avg 7.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 42.8% |
29.6%
13.2 pts worse
|
19.6%
23.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.5% · Q2 49.0% · Q3 40.0% · Q4 36.0% · 4Q avg 42.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.5% |
17.6%
5.9 pts worse
|
16.7%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 22.2% · Q3 23.1% · Q4 26.8% · 4Q avg 23.5% · 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 | 9.7% |
17.3%
7.6 pts better
|
16.3%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 8.4% · Q4 19.8% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.0% |
15.6%
5.6 pts better
|
14.9%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 12.8% · Q3 12.5% · Q4 11.4% · 4Q avg 10.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
1.7%
1.3 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 4.0% · Q3 4.4% · Q4 0.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.5% |
19.8%
4.3 pts better
|
19.8%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 19.0% · Q3 16.0% · Q4 12.2% · 4Q avg 15.5% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
5.5%
1 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 6.0% · Q3 4.6% · Q4 1.7% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.2% |
83.8%
7.4 pts better
|
81.7%
9.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 95.0% · Q3 95.5% · Q4 88.0% · 4Q avg 91.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.8% |
13.9%
7.1 pts better
|
12.0%
5.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.8% · Observed 6.7% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.8%
1.8 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
83.6%
16.4 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.6% |
24.5%
1.1 pts worse
|
23.9%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.6% · Observed 20.0% · Expected 18.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-21 · Fire 2024-03-21
2 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2019-10-11 · Fire 2019-10-11
4 health deficiencies
Top issue: Quality of Life and Care (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
2025-05-08
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2025-05-31
D · Potential for more than minimal harm
2025-05-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-31
F · Potential for more than minimal harm
2024-03-21
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-03-26
F · Potential for more than minimal harm
2024-03-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-28
F · Potential for more than minimal harm
2024-03-21
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-04-01
E · Potential for more than minimal harm
2024-03-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-03-26
E · Potential for more than minimal harm
2024-03-21
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-03-28
E · Potential for more than minimal harm
2024-03-21
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-03-29
E · Potential for more than minimal harm
2024-03-21
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2024-04-19
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-08
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 2025-05-31
D · Potential for more than minimal harm
2025-05-08
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 2025-05-31
D · Potential for more than minimal harm
2025-05-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-31
F · Potential for more than minimal harm
2024-03-21
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-03-30
F · Potential for more than minimal harm
2024-03-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-30
D · Potential for more than minimal harm
2019-10-11
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2019-11-20
D · Potential for more than minimal harm
2019-10-11
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 2019-11-20
D · Potential for more than minimal harm
2019-10-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-11-20
D · Potential for more than minimal harm
2019-10-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-11-20
Penalties and ownership
What sits behind the stars
Ownership
Cox, Douglas
5% Or Greater Direct Ownership Interest · Individual
Cox, Douglas
Operational/Managerial Control · Individual
Cox, Douglas
Corporate Officer · Individual
Cox, Douglas
5% Or Greater Mortgage Interest · Individual
Nee, Stephen
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Signature Healthcare of Hartford Rehab & Wellness
Hartford, KY
4-star overall rating with 4-star inspections with 3 recent health deficiencies
#2
Morgantown Care & Rehabilitation Center
Morgantown, KY
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Fordsville Nursing and Rehabilitation Center
Fordsville, KY
4-star overall rating with 4-star inspections
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