Cycle 1
Health 2024-10-25 · Fire 2024-10-25
7 health deficiencies
Top issue: Environmental (2 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Mount Washington, KY
Green Meadows Health & Rehabilitation
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
310 Boxwood Run Road, Mount Washington, KY
(502) 538-3500
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
122
Certified beds
Average residents
97
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bedrock Healthcare
Operator or chain grouping
Approved since
2009-07-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
9 facilities
Chain averages 1 overall / 1 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
0.41
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.07
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
1.89
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.37
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.48
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
0.44
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
3.14
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,029
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.97
Composite VBP score used to determine payment impact.
Payment multiplier
0.9836
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.18% · Performance 22.66% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.64% · Performance 9.11% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7.12
Baseline 48.44% · Performance 34.57% · Measure score 7.12 · Achievement 7.12 · Improvement 5.38
Adjusted total nurse staffing
2.86
Baseline 2.82 hours · Performance 3.82 hours · Measure score 2.86 · Achievement 2.60 · Improvement 2.86
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.06% |
10.72%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 125 · Observed rate 16.8% · Lower 95% interval 8.76% |
| Discharge to community | 45.59% |
50.57%
5 pts worse
|
No Different than the National Rate · Eligible stays 102 · Observed rate 40.2% · Lower 95% interval 37.69% |
| Medicare spending per beneficiary | 1.22 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 98.88% |
95.27%
3.6 pts better
|
Numerator 88 · Denominator 89 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 89 |
| Discharge self-care score | 53.45% |
53.69%
0.2 pts worse
|
Numerator 31 · Denominator 58 |
| Discharge mobility score | 41.38% |
50.94%
9.6 pts worse
|
Numerator 24 · Denominator 58 |
| Pressure ulcers or injuries, new or worsened | 1.12% |
2.29%
1.2 pts better
|
Numerator 1 · Denominator 89 · Adjusted rate 1% |
| Healthcare-associated infections requiring hospitalization | 9.11% |
7.12%
2 pts worse
|
No Different than the National Rate · Eligible stays 77 · Observed rate 12.99% · Lower 95% interval 5.61% |
| Staff COVID-19 vaccination coverage | 6.61% |
8.2%
1.6 pts worse
|
Numerator 8 · Denominator 121 |
| Staff flu vaccination coverage | 17.7% |
42%
24.3 pts worse
|
Numerator 20 · Denominator 113 |
| Discharge function score | 53.45% |
56.45%
3 pts worse
|
Numerator 31 · Denominator 58 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 46 · Denominator 46 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 28.89% |
25.2%
3.7 pts better
|
Numerator 13 · Denominator 45 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.9
0.9 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.2
0.8 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.4 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
94.3%
2.8 pts better
|
93.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.1% · Q2 96.2% · Q3 96.0% · Q4 100.0% · 4Q avg 97.1% |
| 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 | 0.3% |
3.8%
3.5 pts better
|
3.3%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.0% |
15.2%
3.2 pts better
|
11.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 15.5% · Q3 8.2% · Q4 11.8% · 4Q avg 12.0% |
| 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 5.8% · Q2 7.4% · Q3 4.3% · Q4 5.2% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.9% |
29.6%
6.7 pts better
|
19.6%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.5% · Q2 21.6% · Q3 25.0% · Q4 22.5% · 4Q avg 22.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.8% |
17.6%
5.8 pts better
|
16.7%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 12.0% · Q3 10.2% · Q4 11.3% · 4Q avg 11.8% · 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 | 15.6% |
17.3%
1.7 pts better
|
16.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 18.1% · Q3 15.8% · Q4 7.9% · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.3% |
15.6%
0.3 pts better
|
14.9%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 13.2% · Q3 14.7% · Q4 18.9% · 4Q avg 15.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.7%
0.4 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.4% |
1.7%
1.7 pts worse
|
1.7%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 1.4% · Q3 2.8% · Q4 5.1% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.1% |
19.8%
6.3 pts worse
|
19.8%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 27.8% · Q3 27.5% · Q4 28.1% · 4Q avg 26.1% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
5.5%
3.5 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 2.9% · Q4 3.3% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 80.3% |
83.8%
3.5 pts worse
|
81.7%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 84.6% · Q2 83.8% · Q3 77.0% · Q4 78.0% · 4Q avg 80.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.7% |
13.9%
2.2 pts better
|
12.0%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.7% · Observed 11.1% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
1.8%
1 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 2.0% · Q3 1.8% · Q4 2.3% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.4% |
83.6%
5.8 pts better
|
79.7%
9.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.3% |
24.5%
9.8 pts worse
|
23.9%
10.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.3% · Observed 32.1% · Expected 22.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-06-28 · Fire 2019-06-28
12 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2018-04-26 · Fire 2018-04-26
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-23
F · Potential for more than minimal harm
2024-10-25
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-11-21
F · Potential for more than minimal harm
2024-10-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-11-21
F · Potential for more than minimal harm
2024-10-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-14
F · Potential for more than minimal harm
2024-10-25
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-12-09
E · Potential for more than minimal harm
2024-10-25
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-11-29
E · Potential for more than minimal harm
2024-10-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-10-25
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-14
E · Potential for more than minimal harm
2019-06-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-08-01
D · Potential for more than minimal harm
2019-06-28
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 2019-08-01
D · Potential for more than minimal harm
2019-06-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-08-01
F · Potential for more than minimal harm
2018-04-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-06-19
D · Potential for more than minimal harm
2018-04-26
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2018-06-19
C · Minimal harm
2018-04-26
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2018-06-19
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-10-25
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 2024-12-31
F · Potential for more than minimal harm
2024-10-25
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-12-31
F · Potential for more than minimal harm
2024-10-25
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 2024-12-31
E · Potential for more than minimal harm
2024-10-25
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 2024-12-31
D · Potential for more than minimal harm
2024-10-25
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-10-25
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-12-31
D · Potential for more than minimal harm
2024-10-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-31
E · Potential for more than minimal harm
2019-06-28
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 2019-08-11
E · Potential for more than minimal harm
2019-06-28
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 2019-08-11
D · Potential for more than minimal harm
2019-06-28
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2019-08-11
D · Potential for more than minimal harm
2019-06-28
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 2019-08-11
D · Potential for more than minimal harm
2019-06-28
F642 · Resident Assessment and Care Planning Deficiencies
Health
Ensure a qualified health professional conducts resident assessments.
Corrected 2019-08-11
D · Potential for more than minimal harm
2019-06-28
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 2019-08-11
D · Potential for more than minimal harm
2019-06-28
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 2019-08-11
D · Potential for more than minimal harm
2019-06-28
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-08-11
D · Potential for more than minimal harm
2019-06-28
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 2019-08-11
D · Potential for more than minimal harm
2019-06-28
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 2019-08-11
D · Potential for more than minimal harm
2019-06-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-08-11
D · Potential for more than minimal harm
2019-06-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-08-11
D · Potential for more than minimal harm
2018-04-26
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 2018-06-19
D · Potential for more than minimal harm
2018-04-26
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 2018-06-19
D · Potential for more than minimal harm
2018-04-26
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2018-06-19
Penalties and ownership
What sits behind the stars
Ownership
Tky 2 SNF Operations Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Carver, Dillion
Operational/Managerial Control · Individual
Carver, Dillion
Corporate Director · Individual
Idels, Shimon
Operational/Managerial Control · Individual
Lion 26 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Sabrina 1818 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Saessy Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Schwartz, Steven
Operational/Managerial Control · Individual
Tatiriq Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Tky 2 SNF Operations Holdings LLC
Operational/Managerial Control · Organization
Wathan, Sherrie
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Sanders Ridge Health Campus
Mount Washington, KY
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Glen Ridge Health Campus
Louisville, KY
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Wesley Manor
Louisville, KY
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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