Cycle 1
Health 2024-12-13 · Fire 2024-12-13
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Georgetown, KY
Dover Nursing & Rehabilitation Center
1-star overall rating with 2-star inspections with $170,733 in total fines with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
112 Dover Drive, Georgetown, KY
(502) 863-9529
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
85
Certified beds
Average residents
77
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bluegrass Health Ky
Operator or chain grouping
Approved since
1991-07-14
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
0.53
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
2.48
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.87
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
3.53
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.31
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
0.43
CMS adjusted RN staffing hours
Adjusted total hours
3.15
CMS adjusted total nurse staffing hours
Case-mix index
1.68
Higher values indicate more complex resident acuity
RN turnover
53%
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
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.20% · Performance 21.27% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.47% · Performance 9.09% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Performance 76.19% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.12 hours · Performance 3.12 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.31% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 53 · Observed rate 15.09% · Lower 95% interval 8.09% |
| Discharge to community | 41.2% |
50.57%
9.4 pts worse
|
No Different than the National Rate · Eligible stays 31 · Observed rate 32.26% · Lower 95% interval 27.92% |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 93.1% |
95.27%
2.2 pts worse
|
Numerator 27 · Denominator 29 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 29 |
| Discharge self-care score | 23.81% |
53.69%
29.9 pts worse
|
Numerator 5 · Denominator 21 |
| Discharge mobility score | 28.57% |
50.94%
22.4 pts worse
|
Numerator 6 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 10.34% |
2.29%
8.1 pts worse
|
Numerator 3 · Denominator 29 · Adjusted rate 8.32% |
| Healthcare-associated infections requiring hospitalization | 9.09% |
7.12%
2 pts worse
|
No Different than the National Rate · Eligible stays 31 · Observed rate 19.35% · Lower 95% interval 5.51% |
| Staff COVID-19 vaccination coverage | 1.64% |
8.2%
6.6 pts worse
|
Numerator 2 · Denominator 122 |
| Staff flu vaccination coverage | 12.3% |
42%
29.7 pts worse
|
Numerator 15 · Denominator 122 |
| Discharge function score | 33.33% |
56.45%
23.1 pts worse
|
Numerator 7 · Denominator 21 |
| 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 10 · 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 | 0.6 |
1.9
1.3 pts better
|
1.9
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.2
0.1 pts better
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.9% |
94.3%
2.4 pts worse
|
93.4%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 85.5% · Q2 92.9% · Q3 93.1% · Q4 95.9% · 4Q avg 91.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 85.3% |
96.2%
10.9 pts worse
|
95.5%
10.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 85.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.6% |
3.8%
0.8 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 4.3% · Q3 2.8% · Q4 2.7% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 17.0% |
15.2%
1.8 pts worse
|
11.4%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 15.9% · Q3 9.7% · Q4 20.3% · 4Q avg 17.0% |
| Percentage of long-stay residents who lose too much weight | 11.2% |
6.7%
4.5 pts worse
|
5.4%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 10.8% · Q3 4.7% · Q4 13.1% · 4Q avg 11.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 37.8% |
29.6%
8.2 pts worse
|
19.6%
18.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.7% · Q2 36.9% · Q3 35.9% · Q4 38.7% · 4Q avg 37.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.5% |
17.6%
1.9 pts worse
|
16.7%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 19.3% · Q3 17.0% · Q4 20.0% · 4Q avg 19.5% · 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 | 28.6% |
17.3%
11.3 pts worse
|
16.3%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.3% · Q2 15.5% · Q3 37.6% · Q4 12.3% · 4Q avg 28.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.2% |
15.6%
0.6 pts worse
|
14.9%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 8.6% · Q3 22.0% · Q4 7.4% · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.7%
0.2 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.8% |
1.7%
1.1 pts worse
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 2.9% · Q3 0.0% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.8% |
19.8%
5 pts worse
|
19.8%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.5% · Q2 22.6% · Q3 15.7% · Q4 32.3% · 4Q avg 24.8% |
| Percentage of long-stay residents with pressure ulcers | 8.0% |
5.5%
2.5 pts worse
|
5.1%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.2% · Q2 6.4% · Q3 5.0% · Q4 9.5% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.6% |
83.8%
5.8 pts better
|
81.7%
7.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 77.3% · Q2 84.6% · Q3 95.1% · Q4 100.0% · 4Q avg 89.6% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.8%
0.1 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 0.0% · Q4 3.7% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 76.3% |
83.6%
7.3 pts worse
|
79.7%
3.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 76.3% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-13 · Fire 2023-12-13
23 health deficiencies
Top issue: Resident Rights (8 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2022-09-09 · Fire 2022-09-09
4 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2026-01-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-02-02
F · Potential for more than minimal harm
2025-05-19
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-06-04
F · Potential for more than minimal harm
2024-12-13
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-01-05
E · Potential for more than minimal harm
2024-12-13
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-01-05
F · Potential for more than minimal harm
2023-12-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-18
F · Potential for more than minimal harm
2023-12-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-24
E · Potential for more than minimal harm
2023-12-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-01-18
D · Potential for more than minimal harm
2023-12-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-18
D · Potential for more than minimal harm
2023-12-13
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-01-18
D · Potential for more than minimal harm
2023-12-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-01-18
D · Potential for more than minimal harm
2023-12-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-01-18
F · Potential for more than minimal harm
2022-09-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-24
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-12-13
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 2025-01-05
D · Potential for more than minimal harm
2024-12-13
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 2025-01-05
G · Actual harm
2023-12-13
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 2024-02-01
F · Potential for more than minimal harm
2023-12-13
F575 · Resident Rights Deficiencies
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2024-02-01
F · Potential for more than minimal harm
2023-12-13
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-02-01
F · Potential for more than minimal harm
2023-12-13
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 2024-02-01
E · Potential for more than minimal harm
2023-12-13
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 2024-02-01
E · Potential for more than minimal harm
2023-12-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-12
D · Potential for more than minimal harm
2023-12-13
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 2024-02-01
D · Potential for more than minimal harm
2023-12-13
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-13
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 2024-02-01
D · Potential for more than minimal harm
2023-12-13
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-13
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-13
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-13
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-13
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-13
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-13
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 2024-02-01
D · Potential for more than minimal harm
2023-12-13
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 2024-02-01
D · Potential for more than minimal harm
2023-12-13
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-13
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 2024-02-01
D · Potential for more than minimal harm
2023-12-13
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-13
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-02-01
E · Potential for more than minimal harm
2022-09-09
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 2022-10-24
D · Potential for more than minimal harm
2022-09-09
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2022-10-24
D · Potential for more than minimal harm
2022-09-09
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 2022-10-24
D · Potential for more than minimal harm
2022-09-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-24
Penalties and ownership
What sits behind the stars
$163,742
2023-12-13
Fine
Fine · fine $163,742
Fine
$2,098
2023-08-14
Fine
Fine · fine $2,098
Fine
$1,748
2023-08-07
Fine
Fine · fine $1,748
Fine
$3,145
2023-07-17
Fine
Fine · fine $3,145
Fine
Ownership
Dover Manor Operations Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Fischl, Mayer
5% Or Greater Indirect Ownership Interest · Individual
Grinspan, Eli
5% Or Greater Indirect Ownership Interest · Individual
Landa, Benjamin
5% Or Greater Indirect Ownership Interest · Individual
Fischl, Mayer
Operational/Managerial Control · Individual
Grinspan, Eli
Operational/Managerial Control · Individual
Grinspan, Eli
Corporate Officer · Individual
Huntington Bank
5% Or Greater Mortgage Interest · Organization
Rayburn, Natasha
Operational/Managerial Control · Individual
Valley Stream Operator I LLC
Operational/Managerial Control · Organization
Nearby options
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#3
The Home Place At Midway
Midway, KY
3-star overall rating with 2-star inspections with $4,147 in total fines with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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