Cycle 1
Health 2025-03-06 · Fire 2025-03-06
4 health deficiencies
Top issue: Infection Control (1 deficiency)
12 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Madisonville, KY
Brighton Cornerstone Group, LLC
3-star overall rating with 3-star inspections with $3,387 in total fines with 4 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
55 East North Street, Madisonville, KY
(270) 821-1492
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
40
Certified beds
Average residents
32
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.34
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
3.40
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
4.62
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.22
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.15
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.31
CMS adjusted RN staffing hours
Adjusted total hours
4.22
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
41%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,638
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
55.10
Composite VBP score used to determine payment impact.
Payment multiplier
1.0101
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
6.41
Baseline 100.00% · Performance 48.08% · Measure score 6.41 · Achievement 3.82 · Improvement 6.41
Adjusted total nurse staffing
4.61
Baseline 3.81 hours · Performance 4.39 hours · Measure score 4.61 · Achievement 4.61 · Improvement 2.46
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.37% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 25 · Observed rate 16% · Lower 95% interval 6.79% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.33 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 22 · Denominator 22 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 22 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 22 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.45% |
8.2%
6.7 pts worse
|
Numerator 1 · Denominator 69 |
| Staff flu vaccination coverage | 38.24% |
42%
3.8 pts worse
|
Numerator 26 · Denominator 68 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · 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 | 1.4 |
1.9
0.5 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.0 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
2.2
0.2 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 1.9 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.6% |
94.3%
3.3 pts better
|
93.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 96.9% · Q3 96.9% · Q4 100.0% · 4Q avg 97.6% |
| 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 | 5.5% |
3.8%
1.7 pts worse
|
3.3%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 6.2% · Q3 6.2% · Q4 3.1% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.9% |
15.2%
9.3 pts better
|
11.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 6.5% · Q3 6.9% · Q4 6.7% · 4Q avg 5.9% |
| Percentage of long-stay residents who lose too much weight | 9.1% |
6.7%
2.4 pts worse
|
5.4%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 3.4% · Q3 0.0% · Q4 6.5% · 4Q avg 9.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.7% |
29.6%
13.9 pts better
|
19.6%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 12.5% · Q3 15.6% · Q4 18.8% · 4Q avg 15.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 33.0% |
17.6%
15.4 pts worse
|
16.7%
16.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 32.0% · Q3 31.8% · Q4 37.5% · 4Q avg 33.0% · 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 | 24.4% |
17.3%
7.1 pts worse
|
16.3%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.0% |
15.6%
0.6 pts better
|
14.9%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 11.5% · Q3 18.5% · Q4 10.7% · 4Q avg 15.0% · 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 | 2.5% |
1.7%
0.8 pts worse
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 3.3% · Q3 0.0% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.7% |
19.8%
13.1 pts better
|
19.8%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 7.2% · Q3 9.7% · Q4 6.4% · 4Q avg 6.7% |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
5.5%
0.9 pts worse
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 3.2% · Q3 8.3% · Q4 5.0% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 73.7% |
83.8%
10.1 pts worse
|
81.7%
8 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 73.7% |
| 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 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-03-04 · Fire 2020-03-04
0 health deficiencies
No concentrated health issue counts in this cycle.
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2018-12-13 · Fire 2018-12-13
4 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-06
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2025-03-28
F · Potential for more than minimal harm
2025-03-06
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-04-20
F · Potential for more than minimal harm
2025-03-06
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-04-20
F · Potential for more than minimal harm
2025-03-06
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-04-20
F · Potential for more than minimal harm
2025-03-06
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 2025-04-30
F · Potential for more than minimal harm
2025-03-06
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-03-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-25
F · Potential for more than minimal harm
2025-03-06
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-04-30
E · Potential for more than minimal harm
2025-03-06
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2025-03-07
E · Potential for more than minimal harm
2025-03-06
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-04-20
E · Potential for more than minimal harm
2025-03-06
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 2025-04-20
E · Potential for more than minimal harm
2025-03-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-20
F · Potential for more than minimal harm
2020-03-04
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2020-03-27
F · Potential for more than minimal harm
2020-03-04
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2020-04-14
E · Potential for more than minimal harm
2020-03-04
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2020-03-31
E · Potential for more than minimal harm
2020-03-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-03-31
D · Potential for more than minimal harm
2020-03-04
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2020-03-09
D · Potential for more than minimal harm
2020-03-04
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2020-03-31
D · Potential for more than minimal harm
2020-03-04
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2020-03-31
D · Potential for more than minimal harm
2020-03-04
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 2020-03-31
D · Potential for more than minimal harm
2020-03-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-03-31
D · Potential for more than minimal harm
2020-03-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-03-26
D · Potential for more than minimal harm
2020-03-04
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-03-26
D · Potential for more than minimal harm
2020-03-04
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2020-03-31
F · Potential for more than minimal harm
2018-12-13
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2018-12-13
D · Potential for more than minimal harm
2018-12-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-01-10
D · Potential for more than minimal harm
2018-12-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-01-11
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-06
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 2025-04-30
E · Potential for more than minimal harm
2025-03-06
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-03-06
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 2025-04-30
D · Potential for more than minimal harm
2025-03-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-30
F · Potential for more than minimal harm
2018-12-13
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 2019-01-11
D · Potential for more than minimal harm
2018-12-13
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 2019-01-11
D · Potential for more than minimal harm
2018-12-13
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 2019-01-11
D · Potential for more than minimal harm
2018-12-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-01-11
Penalties and ownership
What sits behind the stars
$3,387
2024-01-30
Fine
Fine · fine $3,387
Fine
Ownership
Frances, Jay
Operational/Managerial Control · Individual
Frances, Jay
Corporate Officer · Individual
Legacy Health Services Inc
Operational/Managerial Control · Organization
Smith, Kimberly
Operational/Managerial Control · Individual
Smith, Kimberly
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Madisonville Health and Rehabilitation, LLC
Madisonville, KY
3-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Park Grove Nursing and Rehabilitation Center
Madisonville, KY
1-star overall rating with 2-star inspections with $12,860 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Ridgewood Terrace Health and Rehabilitation Center
Madisonville, KY
4-star overall rating with 5-star inspections with 1 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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