Sandy Hook, KY

Elliott Nursing and Rehabilitation

3-star overall rating with 2-star inspections with $12,844 in total fines with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle

20 Howards Creek Road, Sandy Hook, KY

(606) 738-9400

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

75

Certified beds

Average residents

71

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

David Marx

Operator or chain grouping

Approved since

1995-12-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

10 facilities

Chain averages 2 overall / 3 health / 2 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

0.48

Registered nurse staffing · state 0.77 · national 0.68

LPN hours / resident day

0.56

Licensed practical nurse staffing · state 0.81 · national 0.87

Aide hours / resident day

2.10

Nurse aide staffing · state 2.43 · national 2.35

Total nurse hours

3.14

All reported nurse hours · state 4.01 · national 3.89

Licensed hours

1.04

RN + LPN hours · state 1.58 · national 1.54

Weekend hours

2.81

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

0.39

CMS adjusted RN staffing hours

Adjusted total hours

2.56

CMS adjusted total nurse staffing hours

Case-mix index

1.68

Higher values indicate more complex resident acuity

RN turnover

22%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

43%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,737

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

19.30

Composite VBP score used to determine payment impact.

Payment multiplier

0.9821

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0.74

Baseline 21.84% · Performance 21.25% · Measure score 0.74 · Achievement 0 · Improvement 0.74

Healthcare-associated infections

2.48

Baseline 7.49% · Performance 7.09% · Measure score 2.48 · Achievement 2.48 · Improvement 1.10

Total nurse turnover

4.50

Baseline 63.77% · Performance 45.28% · Measure score 4.50 · Achievement 4.50 · Improvement 4.25

Adjusted total nurse staffing

0

Baseline 3.02 hours · Performance 2.70 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.5%	10.72% 0.8 pts worse	No Different than the National Rate · Eligible stays 71 · Observed rate 15.49% · Lower 95% interval 8.81%
Discharge to community	45.4%	50.57% 5.2 pts worse	No Different than the National Rate · Eligible stays 41 · Observed rate 36.59% · Lower 95% interval 34.9%
Medicare spending per beneficiary	1.3	1.02 0.3 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 29 · Denominator 29
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 29
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	3.45%	2.29% 1.2 pts worse	Numerator 1 · Denominator 29 · Adjusted rate 2.71%
Healthcare-associated infections requiring hospitalization	7.09%	7.12% About the same	No Different than the National Rate · Eligible stays 36 · Observed rate 8.33% · Lower 95% interval 4.06%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 58
Staff flu vaccination coverage	5.62%	42% 36.4 pts worse	Numerator 5 · Denominator 89
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 13 · 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	2.7	1.9 0.8 pts worse	1.9 0.8 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.5 · Expected 1.8 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	4.8	2.2 2.6 pts worse	1.8 3 pts worse	Long Stay · 20240701-20250630 · Adjusted 4.8 · Observed 4.5 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.6%	94.3% 5.3 pts better	93.4% 6.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.6%	96.2% 2.4 pts better	95.5% 3.1 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6%
Percentage of long-stay residents experiencing one or more falls with major injury	1.1%	3.8% 2.7 pts better	3.3% 2.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 1.1% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	98.0%	15.2% 82.8 pts worse	11.4% 86.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.7% · Q3 98.4% · Q4 98.4% · 4Q avg 98.0%
Percentage of long-stay residents who lose too much weight	3.9%	6.7% 2.8 pts better	5.4% 1.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.9% · Q3 3.3% · Q4 6.2% · 4Q avg 3.9%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	35.7%	29.6% 6.1 pts worse	19.6% 16.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 38.1% · Q2 35.2% · Q3 33.8% · Q4 35.8% · 4Q avg 35.7%
Percentage of long-stay residents who received an antipsychotic medication	3.8%	17.6% 13.8 pts better	16.7% 12.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.5% · Q3 5.5% · Q4 3.8% · 4Q avg 3.8% · 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	1.6%	17.3% 15.7 pts better	16.3% 14.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 0.0% · Q4 3.5% · 4Q avg 1.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	2.3%	15.6% 13.3 pts better	14.9% 12.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 4.2% · Q3 0.0% · Q4 1.6% · 4Q avg 2.3% · 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	0.7%	1.7% 1 pts better	1.7% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	22.1%	19.8% 2.3 pts worse	19.8% 2.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 36.1% · Q2 25.2% · Q3 14.0% · Q4 15.1% · 4Q avg 22.1%
Percentage of long-stay residents with pressure ulcers	0.4%	5.5% 5.1 pts better	5.1% 4.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	83.8% 16.2 pts better	81.7% 18.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q4 100.0% · 4Q avg 100.0%
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	80.0%	83.6% 3.6 pts worse	79.7% 0.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 80.0%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-04-10 · Fire 2025-04-10

2 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2024-04-20 · Fire 2024-04-20

5 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)

8 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)

Cycle 3 Health 2022-05-04 · Fire 2022-05-04

2 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)

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 2025-04-10

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2025-05-01

E · Potential for more than minimal harm 2025-04-10

K781 · Miscellaneous Deficiencies

Fire Safety

Have restrictions on the use of portable space heaters.

Corrected 2025-05-01

E · Potential for more than minimal harm 2025-04-10

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-05-01

F · Potential for more than minimal harm 2024-04-20

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2024-05-10

F · Potential for more than minimal harm 2024-04-20

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-05-23

F · Potential for more than minimal harm 2024-04-20

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-05-10

F · Potential for more than minimal harm 2024-04-20

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-05-10

F · Potential for more than minimal harm 2024-04-20

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 2024-05-10

F · Potential for more than minimal harm 2024-04-20

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-05-10

F · Potential for more than minimal harm 2024-04-20

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2024-05-21

D · Potential for more than minimal harm 2024-04-20

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-05-10

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-04-10

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 2025-05-01

D · Potential for more than minimal harm 2025-04-10

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2025-05-01

J · Immediate jeopardy 2024-04-20

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-05-10

G · Actual harm 2024-04-20

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 2024-05-10

G · Actual harm 2024-04-20

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-05-10

D · Potential for more than minimal harm 2024-04-20

F561 · Resident Rights Deficiencies

Health

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Corrected 2024-05-10

D · Potential for more than minimal harm 2024-04-20

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 2024-05-10

J · Immediate jeopardy 2022-05-04

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 2022-05-11

J · Immediate jeopardy 2022-05-04

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 2022-05-11

Penalties and ownership

What sits behind the stars

$12,844 2024-04-20

Fine

Fine · fine $12,844

Fine

$0 2024-04-20

Payment Denial

Payment Denial · denial start 2024-05-18 · 5 days

5 day denial

Ownership

Elliott Nursing And Rehabilitation Holdings LLC

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 2019-08-30

Marx, David

5% Or Greater Indirect Ownership Interest · Individual

100% 30 facilities 2019-07-25

Alexander, James