Cycle 1
Health 2024-08-29 · Fire 2024-08-29
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Warsaw, KY
Gallatin Nursing and Rehab
2-star overall rating with 2-star inspections with abuse icon flag with $13,800 in total fines with 2 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
499 Center Street, Warsaw, KY
(859) 567-4548
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
110
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1992-09-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 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
0.43
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.13
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
3.66
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.15
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.32
CMS adjusted RN staffing hours
Adjusted total hours
2.74
CMS adjusted total nurse staffing hours
Case-mix index
1.83
Higher values indicate more complex resident acuity
RN turnover
7%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,534
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.40
Composite VBP score used to determine payment impact.
Payment multiplier
0.9842
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.37
Baseline 19.54% · Performance 19.87% · Measure score 3.37 · Achievement 3.37 · Improvement 0
Healthcare-associated infections
0
Baseline 6.30% · Performance 11.87% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7.19
Baseline 60.15% · Performance 34.29% · Measure score 7.19 · Achievement 7.19 · Improvement 6.83
Adjusted total nurse staffing
0
Baseline 3.44 hours · Performance 2.85 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.67% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 96 · Observed rate 15.63% · Lower 95% interval 7.82% |
| Discharge to community | 38.11% |
50.57%
12.5 pts worse
|
No Different than the National Rate · Eligible stays 49 · Observed rate 24.49% · Lower 95% interval 25.75% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 53 · Denominator 53 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 53 |
| Discharge self-care score | 35.48% |
53.69%
18.2 pts worse
|
Numerator 11 · Denominator 31 |
| Discharge mobility score | 48.39% |
50.94%
2.5 pts worse
|
Numerator 15 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 1.89% |
2.29%
0.4 pts better
|
Numerator 1 · Denominator 53 · Adjusted rate 1.33% |
| Healthcare-associated infections requiring hospitalization | 11.87% |
7.12%
4.7 pts worse
|
No Different than the National Rate · Eligible stays 49 · Observed rate 24.49% · Lower 95% interval 6.37% |
| Staff COVID-19 vaccination coverage | 6.25% |
8.2%
1.9 pts worse
|
Numerator 9 · Denominator 144 |
| Staff flu vaccination coverage | 16.76% |
42%
25.2 pts worse
|
Numerator 29 · Denominator 173 |
| Discharge function score | 38.71% |
56.45%
17.7 pts worse
|
Numerator 12 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · 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 19 · 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 | 3.3 |
1.9
1.4 pts worse
|
1.9
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 3.3 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
2.2
0.3 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.8 · Expected 1.9 · 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 | 99.1% |
96.2%
2.9 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
3.8%
1.6 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 3.0% · Q3 2.9% · Q4 0.9% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 38.9% |
15.2%
23.7 pts worse
|
11.4%
27.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.6% · Q2 47.4% · Q3 30.5% · Q4 45.9% · 4Q avg 38.9% |
| Percentage of long-stay residents who lose too much weight | 5.7% |
6.7%
1 pts better
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 3.6% · Q3 7.8% · Q4 4.4% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.6% |
29.6%
8 pts better
|
19.6%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 22.1% · Q3 20.7% · Q4 22.7% · 4Q avg 21.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.0% |
17.6%
0.6 pts better
|
16.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 15.5% · Q3 19.8% · Q4 19.1% · 4Q avg 17.0% · 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 | 5.0% |
17.3%
12.3 pts better
|
16.3%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 2.7% · Q3 4.4% · Q4 7.2% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.7% |
15.6%
8.9 pts better
|
14.9%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 4.8% · Q3 9.9% · Q4 6.3% · 4Q avg 6.7% · 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 | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 16.9% |
19.8%
2.9 pts better
|
19.8%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 13.5% · Q3 17.2% · Q4 23.4% · 4Q avg 16.9% |
| Percentage of long-stay residents with pressure ulcers | 1.1% |
5.5%
4.4 pts better
|
5.1%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.0% · Q3 1.0% · Q4 0.8% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
83.8%
15.1 pts better
|
81.7%
17.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.3% · Q3 100.0% · Q4 100.0% · 4Q avg 98.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.7% |
13.9%
9.8 pts worse
|
12.0%
11.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.7% · Observed 24.4% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.8%
0.7 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 2.6% · Q4 3.7% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
83.6%
16.4 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.4% |
24.5%
8.9 pts worse
|
23.9%
9.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.4% · Observed 26.7% · Expected 19.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-07-19 · Fire 2019-07-19
10 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
3 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2018-05-10 · Fire 2018-05-10
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
2024-08-29
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-09-18
F · Potential for more than minimal harm
2024-08-29
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-09-18
F · Potential for more than minimal harm
2024-08-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-11
F · Potential for more than minimal harm
2024-08-29
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 2024-10-18
F · Potential for more than minimal harm
2024-08-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-09
E · Potential for more than minimal harm
2024-08-29
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-09-18
E · Potential for more than minimal harm
2024-08-29
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 2024-09-26
E · Potential for more than minimal harm
2024-08-29
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-10-03
E · Potential for more than minimal harm
2024-08-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-18
E · Potential for more than minimal harm
2024-08-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-18
D · Potential for more than minimal harm
2019-07-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-08-15
D · Potential for more than minimal harm
2019-07-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-08-15
D · Potential for more than minimal harm
2019-07-19
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2019-08-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-29
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.
Not marked corrected
D · Potential for more than minimal harm
2024-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-28
E · Potential for more than minimal harm
2019-07-19
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 2019-08-28
E · Potential for more than minimal harm
2019-07-19
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-08-28
D · Potential for more than minimal harm
2019-07-19
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 2019-08-16
D · Potential for more than minimal harm
2019-07-19
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-08-16
D · Potential for more than minimal harm
2019-07-19
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 2019-08-16
D · Potential for more than minimal harm
2019-07-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-08-16
D · Potential for more than minimal harm
2019-07-19
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2019-08-01
D · Potential for more than minimal harm
2019-07-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-08-16
D · Potential for more than minimal harm
2019-07-19
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 2019-08-21
D · Potential for more than minimal harm
2019-07-19
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 2019-08-16
D · Potential for more than minimal harm
2018-05-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-06-08
D · Potential for more than minimal harm
2018-05-10
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 2018-06-08
D · Potential for more than minimal harm
2018-05-10
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 2018-06-08
D · Potential for more than minimal harm
2018-05-10
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 2018-06-08
Penalties and ownership
What sits behind the stars
$6,900
2024-08-29
Fine
Fine · fine $6,900
Fine
$6,900
2024-08-29
Fine
Fine · fine $6,900
Fine
Ownership
Providence Group Of Kentucky LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Corporate Officer · Individual
Darnold, Stacie
W-2 Managing Employee · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Hancock, Mark
Corporate Officer · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Omoruyi, Osawaru
Contracted Managing Employee · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Providence Group Nh, LLC
5% Or Greater Indirect Ownership Interest · Organization
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#2
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3-star overall rating with 3-star inspections with 6 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Boonespring Transitional Care Center, LLC
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4-star overall rating with 4-star inspections with 1 fire-safety deficiencies in the latest cycle
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