Cycle 1
Health 2024-11-21 · Fire 2024-11-21
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Leitchfield, KY
Grayson Nursing and Rehab Center
4-star overall rating with 4-star inspections with $12,235 in total fines with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
505 William Thomason Byway, Leitchfield, KY
(270) 259-4028
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
72
Certified beds
Average residents
66
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Encore Health Partners
Operator or chain grouping
Approved since
1985-04-19
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
12 facilities
Chain averages 3 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
0.91
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.28
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.67
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
2.97
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.40
CMS adjusted RN staffing hours
Adjusted total hours
3.07
CMS adjusted total nurse staffing hours
Case-mix index
1.64
Higher values indicate more complex resident acuity
RN turnover
17%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,521
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.53
Composite VBP score used to determine payment impact.
Payment multiplier
0.9855
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.73
Baseline 18.42% · Performance 20.17% · Measure score 2.73 · Achievement 2.73 · Improvement 0
Healthcare-associated infections
4.53
Baseline 6.91% · Performance 6.48% · Measure score 4.53 · Achievement 4.53 · Improvement 1.72
Total nurse turnover
4.55
Baseline 53.93% · Performance 45.07% · Measure score 4.55 · Achievement 4.55 · Improvement 2.55
Adjusted total nurse staffing
0
Baseline 3.85 hours · Performance 3.05 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.7% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 127 · Observed rate 9.45% · Lower 95% interval 6.92% |
| Discharge to community | 59.26% |
50.57%
8.7 pts better
|
No Different than the National Rate · Eligible stays 109 · Observed rate 49.54% · Lower 95% interval 48.47% |
| Medicare spending per beneficiary | 1.19 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 72 · Denominator 72 |
| Falls with major injury | 1.39% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 72 |
| Discharge self-care score | 23.64% |
53.69%
30 pts worse
|
Numerator 13 · Denominator 55 |
| Discharge mobility score | 20% |
50.94%
30.9 pts worse
|
Numerator 11 · Denominator 55 |
| Pressure ulcers or injuries, new or worsened | 5.56% |
2.29%
3.3 pts worse
|
Numerator 4 · Denominator 72 · Adjusted rate 5.71% |
| Healthcare-associated infections requiring hospitalization | 6.48% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 75 · Observed rate 5.33% · Lower 95% interval 3.62% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 108 |
| Staff flu vaccination coverage | 25.45% |
42%
16.6 pts worse
|
Numerator 28 · Denominator 110 |
| Discharge function score | 32.73% |
56.45%
23.7 pts worse
|
Numerator 18 · Denominator 55 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 96.97% |
96.28%
0.7 pts better
|
Numerator 32 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 10% |
25.2%
15.2 pts worse
|
Numerator 4 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.9
About the same
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.8 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
2.2
0.2 pts better
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.9 · Expected 1.6 · 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 | 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 | 7.7% |
3.8%
3.9 pts worse
|
3.3%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 8.8% · Q3 3.4% · Q4 7.0% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 23.9% |
15.2%
8.7 pts worse
|
11.4%
12.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 22.2% · Q3 35.7% · Q4 16.4% · 4Q avg 23.9% |
| Percentage of long-stay residents who lose too much weight | 6.8% |
6.7%
0.1 pts worse
|
5.4%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 12.5% · Q3 5.7% · Q4 0.0% · 4Q avg 6.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.0% |
29.6%
6.6 pts better
|
19.6%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 23.2% · Q3 26.8% · Q4 21.8% · 4Q avg 23.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.9% |
17.6%
3.3 pts worse
|
16.7%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 28.0% · Q3 13.0% · Q4 14.3% · 4Q avg 20.9% · 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 | 26.1% |
17.3%
8.8 pts worse
|
16.3%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q3 30.3% · 4Q avg 26.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.0% |
15.6%
3.4 pts worse
|
14.9%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.6% · Q2 19.2% · Q3 20.8% · Q4 12.0% · 4Q avg 19.0% · 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 | 4.0% |
1.7%
2.3 pts worse
|
1.7%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 1.8% · Q3 1.8% · Q4 1.8% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.4% |
19.8%
1.6 pts worse
|
19.8%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 31.0% · Q3 14.4% · Q4 13.2% · 4Q avg 21.4% |
| Percentage of long-stay residents with pressure ulcers | 7.9% |
5.5%
2.4 pts worse
|
5.1%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 6.9% · Q3 8.1% · Q4 5.9% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
83.8%
14.5 pts better
|
81.7%
16.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 98.3% · Q3 98.3% · Q4 98.3% · 4Q avg 98.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.1% |
13.9%
9.2 pts worse
|
12.0%
11.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.1% · Observed 21.1% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.3% |
1.8%
1.5 pts worse
|
1.6%
1.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 2.6% · Q3 0.0% · Q4 5.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.4% |
83.6%
14.8 pts better
|
79.7%
18.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 10.0% |
24.5%
14.5 pts better
|
23.9%
13.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.0% · Observed 9.9% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-12-13 · Fire 2019-12-13
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2018-09-20 · Fire 2018-09-20
9 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-21
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-12-19
F · Potential for more than minimal harm
2024-11-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-19
F · Potential for more than minimal harm
2019-12-13
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 2020-01-22
F · Potential for more than minimal harm
2019-12-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-01-22
D · Potential for more than minimal harm
2019-12-13
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2020-01-22
D · Potential for more than minimal harm
2019-12-13
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2020-01-22
D · 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 2018-10-15
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-11-21
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 2025-01-08
F · Potential for more than minimal harm
2018-09-20
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 2018-10-15
E · Potential for more than minimal harm
2018-09-20
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 2018-10-15
D · Potential for more than minimal harm
2018-09-20
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2018-10-15
D · Potential for more than minimal harm
2018-09-20
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2018-10-15
D · Potential for more than minimal harm
2018-09-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-10-15
D · Potential for more than minimal harm
2018-09-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2018-10-15
D · Potential for more than minimal harm
2018-09-20
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2018-10-15
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 2018-10-15
D · Potential for more than minimal harm
2018-09-20
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2018-10-15
Penalties and ownership
What sits behind the stars
$2,797
2023-10-23
Fine
Fine · fine $2,797
Fine
$2,447
2023-10-17
Fine
Fine · fine $2,447
Fine
$2,098
2023-10-10
Fine
Fine · fine $2,098
Fine
$1,748
2023-10-02
Fine
Fine · fine $1,748
Fine
$3,145
2023-09-11
Fine
Fine · fine $3,145
Fine
Ownership
Encore Parent Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
505 William Thomason Byway Realty LLC
5% Or Greater Mortgage Interest · Organization
Cbre Capital Markets Inc
5% Or Greater Mortgage Interest · Organization
Encore Health Partners 2 LLC
Operational/Managerial Control · Organization
Encore Investors 2 LLC
5% Or Greater Indirect Ownership Interest · Organization
Fischl, Mayer
Operational/Managerial Control · Individual
Fischl, Mayer
Corporate Officer · Individual
Fulkerson, Melinda
Operational/Managerial Control · Individual
Grinspan, Eli
5% Or Greater Indirect Ownership Interest · Individual
Grinspan, Eli
Operational/Managerial Control · Individual
Grinspan, Eli
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Spring View Nursing & Rehabilitation
Leitchfield, KY
1-star overall rating with 1-star inspections with $26,685 in total fines with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Edmonson Nursing And Rehabilitation Center
Brownsville, KY
4-star overall rating with 4-star inspections with 1 fire-safety deficiencies in the latest cycle
#3
Hardinsburg Nursing and Rehabilitation Center
Hardinsburg, KY
4-star overall rating with 4-star inspections with 3 recent health deficiencies
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