Cycle 1
Health 2024-09-13 · Fire 2024-09-13
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Phelps, KY
Good Shepherd Health and Rehabilitation
1-star overall rating with 1-star inspections with $43,646 in total fines with 2 recent health deficiencies
60 Phillips Branch Road, Phelps, KY
(606) 456-8725
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
118
Certified beds
Average residents
88
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Plainview Healthcare Partners
Operator or chain grouping
Approved since
1990-12-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 2 overall / 2 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
0.62
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.79
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.63
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.65
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.57
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.26
CMS adjusted total nurse staffing hours
Case-mix index
1.59
Higher values indicate more complex resident acuity
RN turnover
54%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,462
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.68
Composite VBP score used to determine payment impact.
Payment multiplier
0.9843
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.86
Baseline 19.56% · Performance 20.57% · Measure score 1.86 · Achievement 1.86 · Improvement 0
Healthcare-associated infections
0
Baseline 7.78% · Performance 9.14% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7.82
Baseline 36.56% · Performance 31.71% · Measure score 7.82 · Achievement 7.82 · Improvement 3.64
Adjusted total nurse staffing
0.99
Baseline 2.45 hours · Performance 2.95 hours · Measure score 0.99 · Achievement 0 · Improvement 0.99
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.53% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 22.22% · Lower 95% interval 7.84% |
| Discharge to community | 41.21% |
50.57%
9.4 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 25% · Lower 95% interval 27.77% |
| Medicare spending per beneficiary | 1.64 |
1.02
0.6 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 70 · Denominator 70 |
| Falls with major injury | 1.43% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 70 |
| Discharge self-care score | 60% |
53.69%
6.3 pts better
|
Numerator 18 · Denominator 30 |
| Discharge mobility score | 46.67% |
50.94%
4.3 pts worse
|
Numerator 14 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 1.43% |
2.29%
0.9 pts better
|
Numerator 1 · Denominator 70 · Adjusted rate 0.81% |
| Healthcare-associated infections requiring hospitalization | 9.14% |
7.12%
2 pts worse
|
No Different than the National Rate · Eligible stays 43 · Observed rate 18.6% · Lower 95% interval 6.08% |
| Staff COVID-19 vaccination coverage | 0.78% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 129 |
| Staff flu vaccination coverage | 56.45% |
42%
14.5 pts better
|
Numerator 70 · Denominator 124 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 15 · Denominator 30 |
| Transfer of health information to provider | 97.62% |
95.95%
1.7 pts better
|
Numerator 41 · Denominator 42 |
| 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 | 30.56% |
25.2%
5.4 pts better
|
Numerator 11 · Denominator 36 |
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 3.7 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.0 |
2.2
1.8 pts worse
|
1.8
2.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.0 · Observed 4.4 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
94.3%
4.2 pts better
|
93.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 98.9% · Q3 98.8% · Q4 98.8% · 4Q avg 98.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.2%
3.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.8%
1.2 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 6.9% · Q3 4.8% · Q4 1.2% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
15.2%
15.2 pts better
|
11.4%
11.4 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 who lose too much weight | 4.7% |
6.7%
2 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.1% · Q3 3.8% · Q4 5.2% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.5% |
29.6%
6.1 pts better
|
19.6%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 24.4% · Q3 22.9% · Q4 21.2% · 4Q avg 23.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.6% |
17.6%
3 pts better
|
16.7%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 18.6% · Q3 11.7% · Q4 7.7% · 4Q avg 14.6% · 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 | 5.8% |
17.3%
11.5 pts better
|
16.3%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 4.0% · Q3 3.3% · Q4 0.0% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.0% |
15.6%
9.6 pts better
|
14.9%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 3.8% · Q3 5.2% · Q4 3.8% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.7%
0.3 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.9% · Q3 1.1% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.7%
1.1 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.2% |
19.8%
11.6 pts better
|
19.8%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 9.5% · Q3 7.9% · Q4 9.2% · 4Q avg 8.2% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
5.5%
1.5 pts better
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 4.9% · Q3 4.7% · Q4 0.8% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 67.3% |
83.8%
16.5 pts worse
|
81.7%
14.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 71.4% · Q2 56.8% · Q3 71.2% · Q4 68.8% · 4Q avg 67.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 24.6% |
13.9%
10.7 pts worse
|
12.0%
12.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.6% · Observed 26.6% · Expected 12.1% · 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% · Q2 0.0% · Q3 0.0% · Q4 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 | 73.0% |
83.6%
10.6 pts worse
|
79.7%
6.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 73.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.8% |
24.5%
9.3 pts worse
|
23.9%
9.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.8% · Observed 40.6% · Expected 28.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-31 · Fire 2019-10-31
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2018-10-11 · Fire 2018-10-11
11 health deficiencies
Top issue: Administration (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-09
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-12-23
F · Potential for more than minimal harm
2018-10-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-11-06
Inspection history
Recent health citations
G · Actual harm
2024-09-13
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 2024-09-19
D · Potential for more than minimal harm
2024-09-13
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 2024-09-19
D · Potential for more than minimal harm
2024-09-13
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-09-19
J · Immediate jeopardy
2023-11-17
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 2023-11-18
J · Immediate jeopardy
2023-11-17
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 2023-11-18
J · Immediate jeopardy
2023-11-17
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-11-18
J · Immediate jeopardy
2023-11-17
F837 · Administration Deficiencies
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2023-11-18
J · Immediate jeopardy
2023-11-17
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-11-18
J · Immediate jeopardy
2023-04-20
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 2023-06-16
J · Immediate jeopardy
2023-04-20
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 2023-03-21
E · Potential for more than minimal harm
2023-04-20
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 2023-06-16
D · Potential for more than minimal harm
2019-10-31
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 2019-11-21
D · Potential for more than minimal harm
2019-10-31
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-11-20
D · Potential for more than minimal harm
2019-10-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-15
E · Potential for more than minimal harm
2018-10-11
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2018-10-18
E · Potential for more than minimal harm
2018-10-11
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 2018-10-18
D · Potential for more than minimal harm
2018-10-11
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 2018-10-18
Penalties and ownership
What sits behind the stars
$14,260
2024-09-13
Fine
Fine · fine $14,260
Fine
$5,197
2023-11-17
Fine
Fine · fine $5,197
Fine
$5,197
2023-11-17
Fine
Fine · fine $5,197
Fine
$5,198
2023-11-17
Fine
Fine · fine $5,198
Fine
$6,897
2023-04-20
Fine
Fine · fine $6,897
Fine
$6,897
2023-04-20
Fine
Fine · fine $6,897
Fine
Ownership
Phelps Ky Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Arem, Jeffrey
5% Or Greater Indirect Ownership Interest · Individual
Moskowitz, Isaac
5% Or Greater Indirect Ownership Interest · Individual
Herskowitz, David
5% Or Greater Indirect Ownership Interest · Individual
Herskowitz, David
Operational/Managerial Control · Individual
Hurley, Angelina
Operational/Managerial Control · Individual
Ravi, Pallaki
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Trinity Health Care Of Mingo
Williamson, WV
3-star overall rating with 4-star inspections with $25,237 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Heritage Hall Grundy
Grundy, VA
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Tug Valley ARH Skilled Nursing Facility
South Williamson, KY
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
Jump out