Cycle 1
Health 2025-05-08 · Fire 2025-05-08
0 health deficiencies
No concentrated health issue counts in this cycle.
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Lexington, KY
Cambridge Nursing & Rehabilitation Center
3-star overall rating with 4-star inspections with 6 fire-safety deficiencies in the latest cycle
2020 Cambridge Drive, Lexington, KY
(859) 252-6747
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
108
Certified beds
Average residents
106
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bluegrass Health Ky
Operator or chain grouping
Approved since
2000-03-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 3 overall / 3 health / 1 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
0.41
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.33
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.57
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.23
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.13
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
0.04
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.34
CMS adjusted RN staffing hours
Adjusted total hours
2.91
CMS adjusted total nurse staffing hours
Case-mix index
1.68
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,725
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.72
Composite VBP score used to determine payment impact.
Payment multiplier
0.9830
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.60
Performance 19.76% · Measure score 3.60 · Achievement 3.60 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
2.29
Performance 7.15% · Measure score 2.29 · Achievement 2.29 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
3.2
Baseline 84.61% · Performance 62.50% · Measure score 3.2 · Achievement 0 · Improvement 3.2
Adjusted total nurse staffing
0
Baseline 3.01 hours · Performance 2.81 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.98% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 8.51% · Lower 95% interval 6.59% |
| Discharge to community | 36.26% |
50.57%
14.3 pts worse
|
No Different than the National Rate · Eligible stays 31 · Observed rate 19.35% · Lower 95% interval 25.47% |
| Medicare spending per beneficiary | 1.21 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 89.09% |
95.27%
6.2 pts worse
|
Numerator 49 · Denominator 55 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 55 |
| Discharge self-care score | 62.5% |
53.69%
8.8 pts better
|
Numerator 15 · Denominator 24 |
| Discharge mobility score | 41.67% |
50.94%
9.3 pts worse
|
Numerator 10 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 1.82% |
2.29%
0.5 pts better
|
Numerator 1 · Denominator 55 · Adjusted rate 1.17% |
| Healthcare-associated infections requiring hospitalization | 7.15% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 45 · Observed rate 8.89% · Lower 95% interval 3.79% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 141 |
| Staff flu vaccination coverage | 6.17% |
42%
35.8 pts worse
|
Numerator 10 · Denominator 162 |
| Discharge function score | 58.33% |
56.45%
1.9 pts better
|
Numerator 14 · Denominator 24 |
| Transfer of health information to provider | 90% |
95.95%
6 pts worse
|
Numerator 18 · Denominator 20 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 53.57% |
25.2%
28.4 pts better
|
Numerator 15 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.9
0.4 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.1 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
2.2
1.1 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.1 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.3%
5.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.0% |
96.2%
0.2 pts worse
|
95.5%
0.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
3.8%
1.7 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 3.2% · Q3 1.0% · Q4 1.9% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 19.7% |
15.2%
4.5 pts worse
|
11.4%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 19.0% · Q3 16.9% · Q4 19.6% · 4Q avg 19.7% |
| Percentage of long-stay residents who lose too much weight | 7.7% |
6.7%
1 pts worse
|
5.4%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 9.4% · Q3 10.8% · Q4 5.4% · 4Q avg 7.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.8% |
29.6%
4.2 pts worse
|
19.6%
14.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.5% · Q2 31.8% · Q3 38.9% · Q4 31.6% · 4Q avg 33.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.6% |
17.6%
5 pts worse
|
16.7%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 21.3% · Q3 23.5% · Q4 20.0% · 4Q avg 22.6% · 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 | 10.5% |
17.3%
6.8 pts better
|
16.3%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 12.0% · Q3 6.7% · Q4 4.2% · 4Q avg 10.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.8% |
15.6%
3.8 pts better
|
14.9%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 15.2% · Q3 4.8% · Q4 5.7% · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.7%
0.3 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 0.7% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
1.7%
0.4 pts worse
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 0.0% · Q3 1.0% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.9% |
19.8%
4.9 pts better
|
19.8%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 19.3% · Q3 12.3% · Q4 7.8% · 4Q avg 14.9% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
5.5%
About the same
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 7.1% · Q3 2.8% · Q4 2.9% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.2% |
83.8%
6.4 pts better
|
81.7%
8.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 78.3% · Q2 93.3% · Q3 100.0% · 4Q avg 90.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.7% |
13.9%
1.2 pts better
|
12.0%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.7% · Observed 14.0% · Expected 12.3% · 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 · Q1 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.1% |
83.6%
5.5 pts better
|
79.7%
9.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 38.8% |
24.5%
14.3 pts worse
|
23.9%
14.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 38.8% · Observed 44.0% · Expected 27.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-09-24 · Fire 2020-09-24
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2019-03-14 · Fire 2019-03-14
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
F · Potential for more than minimal harm
2025-05-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-04
E · Potential for more than minimal harm
2025-05-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-06-04
E · Potential for more than minimal harm
2025-05-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-06-04
E · 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 2025-06-04
D · Potential for more than minimal harm
2025-05-08
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 2025-06-04
D · Potential for more than minimal harm
2025-05-08
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-04
E · Potential for more than minimal harm
2020-09-24
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2020-10-31
D · Potential for more than minimal harm
2020-09-24
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2020-10-31
D · Potential for more than minimal harm
2020-09-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-10-31
D · Potential for more than minimal harm
2020-09-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-10-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-08-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-08-22
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 2024-09-13
E · Potential for more than minimal harm
2020-09-24
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 2020-10-31
E · Potential for more than minimal harm
2020-09-24
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 2020-10-31
D · Potential for more than minimal harm
2020-09-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-10-31
D · Potential for more than minimal harm
2019-03-14
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-04-22
D · Potential for more than minimal harm
2019-03-14
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2019-04-22
D · Potential for more than minimal harm
2019-03-14
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 2019-04-22
D · Potential for more than minimal harm
2019-03-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-04-22
Penalties and ownership
What sits behind the stars
Ownership
Cambridge Operations Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Fischl, Mayer
5% Or Greater Indirect Ownership Interest · Individual
Fischl, Mayer
Operational/Managerial Control · Individual
Fischl, Mayer
Corporate Officer · Individual
Grinspan, Eli
Operational/Managerial Control · Individual
Grinspan, Leora
5% Or Greater Indirect Ownership Interest · Individual
Mjem Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Valley Stream Operator I LLC
Operational/Managerial Control · Organization
Vium Cpaital Investments LLC
5% Or Greater Mortgage Interest · Organization
Nearby options
Other facilities in reach
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Cardinal Hill Skilled Rehabilitation Unit
Lexington, KY
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Homestead Post Acute
Lexington, KY
3-star overall rating with 3-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Pine Meadows Post Acute
Lexington, KY
3-star overall rating with 3-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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