Cycle 1
Health 2024-10-19 · Fire 2024-10-19
4 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Burkesville, KY
Cumberland Valley Nursing & Rehabilitation Center
1-star overall rating with 2-star inspections with $24,385 in total fines with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
301 South Main Street, Burkesville, KY
(270) 864-4315
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
84
Certified beds
Average residents
80
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bluegrass Health Ky
Operator or chain grouping
Approved since
1991-06-19
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
0.44
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.42
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.83
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.35
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.18
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
0.36
CMS adjusted RN staffing hours
Adjusted total hours
3.13
CMS adjusted total nurse staffing hours
Case-mix index
1.67
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,986
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.09
Composite VBP score used to determine payment impact.
Payment multiplier
0.9837
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.41
Performance 20.31% · Measure score 2.41 · Achievement 2.41 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.01
Baseline 5.56% · Performance 6.93% · Measure score 3.01 · Achievement 3.01 · Improvement 0
Total nurse turnover
3.20
Baseline 30.91% · Performance 50.59% · Measure score 3.20 · Achievement 3.20 · Improvement 0
Adjusted total nurse staffing
1.41
Baseline 3.5 hours · Performance 3.48 hours · Measure score 1.41 · Achievement 1.41 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.93% |
10.72%
3.2 pts worse
|
No Different than the National Rate · Eligible stays 70 · Observed rate 21.43% · Lower 95% interval 9.18% |
| Discharge to community | 35.58% |
50.57%
15 pts worse
|
Worse than the National Rate · Eligible stays 45 · Observed rate 26.67% · Lower 95% interval 25.8% |
| Medicare spending per beneficiary | 1.35 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 89.29% |
95.27%
6 pts worse
|
Numerator 50 · Denominator 56 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 56 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 16 · Denominator 32 |
| Discharge mobility score | 53.13% |
50.94%
2.2 pts better
|
Numerator 17 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 5.36% |
2.29%
3.1 pts worse
|
Numerator 3 · Denominator 56 · Adjusted rate 3.72% |
| Healthcare-associated infections requiring hospitalization | 6.94% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 6% · Lower 95% interval 3.07% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 136 |
| Staff flu vaccination coverage | 7.65% |
42%
34.4 pts worse
|
Numerator 14 · Denominator 183 |
| Discharge function score | 56.25% |
56.45%
0.2 pts worse
|
Numerator 18 · Denominator 32 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| 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 | 12% |
25.2%
13.2 pts worse
|
Numerator 3 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.9
0.6 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.8 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.6 |
2.2
1.4 pts worse
|
1.8
1.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.6 · Observed 4.1 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
94.3%
4.7 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 98.6% · Q3 100.0% · Q4 98.7% · 4Q avg 99.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
96.2%
1.2 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
3.8%
1.8 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.9% · Q3 1.3% · Q4 2.5% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 56.4% |
15.2%
41.2 pts worse
|
11.4%
45 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 70.6% · Q2 49.2% · Q3 48.6% · Q4 57.3% · 4Q avg 56.4% |
| Percentage of long-stay residents who lose too much weight | 9.5% |
6.7%
2.8 pts worse
|
5.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 12.7% · Q3 10.0% · Q4 8.5% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.2% |
29.6%
4.6 pts worse
|
19.6%
14.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.8% · Q2 32.8% · Q3 31.9% · Q4 37.8% · 4Q avg 34.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 40.1% |
17.6%
22.5 pts worse
|
16.7%
23.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.0% · Q2 43.9% · Q3 39.0% · Q4 32.1% · 4Q avg 40.1% · 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 | 28.4% |
17.3%
11.1 pts worse
|
16.3%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 52.1% · Q2 20.3% · Q3 26.9% · Q4 13.4% · 4Q avg 28.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.8% |
15.6%
10.2 pts worse
|
14.9%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.7% · Q2 32.1% · Q3 17.2% · Q4 15.6% · 4Q avg 25.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.7%
About the same
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
1.7%
0.7 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.2% |
19.8%
9.4 pts worse
|
19.8%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.3% · Q2 20.6% · Q3 33.4% · Q4 28.3% · 4Q avg 29.2% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
5.5%
0.7 pts worse
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 5.7% · Q3 8.4% · Q4 4.2% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.5% |
83.8%
10.7 pts better
|
81.7%
12.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.0% · Q2 92.3% · Q3 97.4% · Q4 100.0% · 4Q avg 94.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.9% |
13.9%
6 pts worse
|
12.0%
7.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.9% · Observed 23.1% · Expected 12.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 9.1% |
1.8%
7.3 pts worse
|
1.6%
7.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 9.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.9% |
83.6%
6.7 pts worse
|
79.7%
2.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.2% |
24.5%
6.3 pts better
|
23.9%
5.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.2% · Observed 23.1% · Expected 30.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-11 · Fire 2019-10-11
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2018-09-20 · Fire 2018-09-20
2 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-10-19
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-11-22
E · Potential for more than minimal harm
2024-10-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-22
E · Potential for more than minimal harm
2024-10-19
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-22
F · Potential for more than minimal harm
2018-09-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-10-16
E · Potential for more than minimal harm
2018-09-20
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2018-10-16
Inspection history
Recent health citations
J · Immediate jeopardy
2024-10-19
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 2024-04-30
J · Immediate jeopardy
2024-10-19
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 2024-04-30
D · Potential for more than minimal harm
2024-10-19
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-10-19
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 2024-11-08
D · Potential for more than minimal harm
2018-09-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-10-12
C · Minimal harm
2018-09-20
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2018-10-12
Penalties and ownership
What sits behind the stars
$6,500
2024-10-19
Fine
Fine · fine $6,500
Fine
$9,146
2024-10-19
Fine
Fine · fine $9,146
Fine
$2,447
2023-06-12
Fine
Fine · fine $2,447
Fine
$2,098
2023-06-05
Fine
Fine · fine $2,098
Fine
$4,194
2023-05-15
Fine
Fine · fine $4,194
Fine
Ownership
Cumberland Ky Opco Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Aaron, Julianne
Operational/Managerial Control · Individual
Dwight Mortgage Trust LLC
5% Or Greater Mortgage Interest · Organization
Encore Health Partners 2 LLC
Operational/Managerial Control · 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, Eli
Corporate Officer · Individual
Grinspan, Leora
5% Or Greater Indirect Ownership Interest · Individual
Kaplan, Judah
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
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5-star overall rating with 5-star inspections with 1 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Celina Health And Rehabilitation Center
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4-star overall rating with 4-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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