Cycle 1
Health 2025-04-24 · Fire 2025-04-24
4 health deficiencies
Top issue: Infection Control (1 deficiency)
14 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Kuttawa, KY
Lake Barkley Health & Rehabilitation
2-star overall rating with 3-star inspections with 4 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
1253 Lake Barkley Drive, Kuttawa, KY
(270) 388-2291
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
65
Certified beds
Average residents
51
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lyon Healthcare
Operator or chain grouping
Approved since
1991-12-09
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.47
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.53
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.34
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.34
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.00
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
2.98
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.33
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
0.44
CMS adjusted RN staffing hours
Adjusted total hours
3.10
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
100%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
77%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,382
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
5.89
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.36
Baseline 18.90% · Performance 20.34% · Measure score 2.36 · Achievement 2.36 · Improvement 0
Healthcare-associated infections
0
Baseline 6.21% · Performance 8.18% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 70.21% · Performance 69.56% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.29 hours · Performance 2.82 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.8% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 3.03% · Lower 95% interval 6.2% |
| Discharge to community | 39.33% |
50.57%
11.2 pts worse
|
No Different than the National Rate · Eligible stays 26 · Observed rate 26.92% · Lower 95% interval 25.41% |
| Medicare spending per beneficiary | 1.4 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 94.59% |
95.27%
0.7 pts worse
|
Numerator 35 · Denominator 37 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 37 |
| Discharge self-care score | 44.44% |
53.69%
9.2 pts worse
|
Numerator 12 · Denominator 27 |
| Discharge mobility score | 44.44% |
50.94%
6.5 pts worse
|
Numerator 12 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 8.11% |
2.29%
5.8 pts worse
|
Numerator 3 · Denominator 37 · Adjusted rate 6.8% |
| Healthcare-associated infections requiring hospitalization | 8.18% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 33 · Observed rate 12.12% · Lower 95% interval 5.15% |
| Staff COVID-19 vaccination coverage | 1.43% |
8.2%
6.8 pts worse
|
Numerator 1 · Denominator 70 |
| Staff flu vaccination coverage | 6.1% |
42%
35.9 pts worse
|
Numerator 5 · Denominator 82 |
| Discharge function score | 48.15% |
56.45%
8.3 pts worse
|
Numerator 13 · Denominator 27 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| 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 | 14.29% |
25.2%
10.9 pts worse
|
Numerator 3 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.9
0.8 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.3 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
2.2
0.5 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.9 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 83.7% |
94.3%
10.6 pts worse
|
93.4%
9.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 63.0% · Q2 97.5% · Q3 94.4% · Q4 84.1% · 4Q avg 83.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.5% |
96.2%
2.7 pts worse
|
95.5%
2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.8% |
3.8%
1 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.5% · Q3 8.3% · Q4 6.8% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 29.2% |
15.2%
14 pts worse
|
11.4%
17.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.0% · Q2 16.7% · Q3 19.4% · Q4 43.9% · 4Q avg 29.2% |
| Percentage of long-stay residents who lose too much weight | 12.0% |
6.7%
5.3 pts worse
|
5.4%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 10.5% · Q3 25.0% · Q4 9.1% · 4Q avg 12.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 41.4% |
29.6%
11.8 pts worse
|
19.6%
21.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.9% · Q2 43.6% · Q3 41.7% · Q4 38.6% · 4Q avg 41.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.5% |
17.6%
8.1 pts better
|
16.7%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 14.3% · Q3 7.4% · Q4 10.5% · 4Q avg 9.5% · 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 | 6.5% |
17.3%
10.8 pts better
|
16.3%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.5% |
15.6%
1.1 pts better
|
14.9%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 6.2% · Q3 20.0% · Q4 18.4% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.0% |
0.7%
1.3 pts worse
|
1.0%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 4.1% · Q4 1.6% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.9% |
1.7%
3.2 pts worse
|
1.7%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 5.1% · Q3 8.3% · Q4 2.3% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.6% |
19.8%
3.8 pts worse
|
19.8%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.7% · Q2 23.5% · Q3 21.0% · Q4 17.3% · 4Q avg 23.6% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
5.5%
2 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 13.6% · Q3 7.5% · Q4 4.3% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 51.2% |
83.8%
32.6 pts worse
|
81.7%
30.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 73.0% · Q2 66.7% · Q3 33.3% · Q4 34.1% · 4Q avg 51.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.7% |
13.9%
1.8 pts worse
|
12.0%
3.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.7% · Observed 16.7% · Expected 11.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.5% |
1.8%
1.7 pts worse
|
1.6%
1.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 9.5% · Q4 4.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 60.0% |
83.6%
23.6 pts worse
|
79.7%
19.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 60.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.5% |
24.5%
2 pts better
|
23.9%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.5% · Observed 23.8% · Expected 25.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-02-14 · Fire 2020-02-14
8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-01-30 · Fire 2019-01-30
7 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-24
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-04-24
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-04-24
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-08-08
F · Potential for more than minimal harm
2025-04-24
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-07-01
F · Potential for more than minimal harm
2025-04-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-01
F · Potential for more than minimal harm
2025-04-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-07-01
F · Potential for more than minimal harm
2025-04-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-07-01
F · Potential for more than minimal harm
2025-04-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-01
E · Potential for more than minimal harm
2025-04-24
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 2025-07-01
E · Potential for more than minimal harm
2025-04-24
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-04-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-04-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-04-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-07-01
D · Potential for more than minimal harm
2025-04-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-07-01
E · Potential for more than minimal harm
2020-02-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-03-03
D · Potential for more than minimal harm
2020-02-14
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 2020-03-05
D · Potential for more than minimal harm
2020-02-14
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 2020-04-10
E · Potential for more than minimal harm
2019-01-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-01-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-24
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-24
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 2025-05-15
D · Potential for more than minimal harm
2025-04-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-15
C · Minimal harm
2025-04-24
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-05-15
F · Potential for more than minimal harm
2020-02-14
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 2020-03-20
D · Potential for more than minimal harm
2020-02-14
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 2020-03-20
D · Potential for more than minimal harm
2020-02-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-03-20
D · Potential for more than minimal harm
2020-02-14
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 2020-03-20
D · Potential for more than minimal harm
2020-02-14
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2020-03-20
D · Potential for more than minimal harm
2020-02-14
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2020-03-20
D · Potential for more than minimal harm
2020-02-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-03-20
B · Minimal harm
2020-02-14
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2020-03-20
F · Potential for more than minimal harm
2019-01-30
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-03-09
D · Potential for more than minimal harm
2019-01-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-03-09
D · Potential for more than minimal harm
2019-01-30
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2019-03-09
D · Potential for more than minimal harm
2019-01-30
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 2019-03-09
D · Potential for more than minimal harm
2019-01-30
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2019-03-09
D · Potential for more than minimal harm
2019-01-30
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 2019-03-09
D · Potential for more than minimal harm
2019-01-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-03-09
Penalties and ownership
What sits behind the stars
Ownership
Carver, Dillion
Operational/Managerial Control · Individual
Hall, Michelle
Operational/Managerial Control · Individual
Hartley, Beth
Operational/Managerial Control · Individual
Idels, Shimon
Operational/Managerial Control · Individual
Ky 10 SNF Operations Holdings LLC
Operational/Managerial Control · Organization
Ky10 SNF Opco Manager LLC
Operational/Managerial Control · Organization
Loney, Leigh
Operational/Managerial Control · Individual
Nearby options
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#2
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3-star overall rating with 4-star inspections
#3
Calvert City Convalescent Center
Calvert City, KY
4-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
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