Cycle 1
Health 2025-07-03 · Fire 2025-07-03
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Manchester, KY
Landmark of Laurel Creek Rehabilitation and Nursin
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1033 North Highway 11, Manchester, KY
(606) 598-6163
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
106
Certified beds
Average residents
92
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lyon Healthcare
Operator or chain grouping
Approved since
1991-08-15
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
0.48
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.04
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.09
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
2.75
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.40
CMS adjusted RN staffing hours
Adjusted total hours
2.56
CMS adjusted total nurse staffing hours
Case-mix index
1.62
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,758
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.80
Composite VBP score used to determine payment impact.
Payment multiplier
0.9867
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.41
Baseline 18.50% · Performance 19.85% · Measure score 3.41 · Achievement 3.41 · Improvement 0
Healthcare-associated infections
2.19
Baseline 9.07% · Performance 7.98% · Measure score 2.19 · Achievement 0 · Improvement 2.19
Total nurse turnover
7.12
Baseline 39.13% · Performance 34.57% · Measure score 7.12 · Achievement 7.12 · Improvement 2.69
Adjusted total nurse staffing
0
Baseline 2.48 hours · Performance 2.55 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.83% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 59 · Observed rate 8.47% · Lower 95% interval 6.28% |
| Discharge to community | 45.27% |
50.57%
5.3 pts worse
|
No Different than the National Rate · Eligible stays 39 · Observed rate 35.9% · Lower 95% interval 32.47% |
| Medicare spending per beneficiary | 1.71 |
1.02
0.7 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 28 · Denominator 28 |
| Falls with major injury | 3.57% |
0.77%
2.8 pts worse
|
Numerator 1 · Denominator 28 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 3.57% |
2.29%
1.3 pts worse
|
Numerator 1 · Denominator 28 · Adjusted rate 2.02% |
| Healthcare-associated infections requiring hospitalization | 7.98% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 13.89% · Lower 95% interval 4.58% |
| Staff COVID-19 vaccination coverage | 29.81% |
8.2%
21.6 pts better
|
Numerator 31 · Denominator 104 |
| Staff flu vaccination coverage | 81.75% |
42%
39.8 pts better
|
Numerator 103 · Denominator 126 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 30.43% |
25.2%
5.2 pts better
|
Numerator 7 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.9
0.6 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 3.3 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.2
0.1 pts better
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.7 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
94.3%
5.4 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| 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 | 1.6% |
3.8%
2.2 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 2.6% · Q3 1.3% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 15.8% |
15.2%
0.6 pts worse
|
11.4%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 19.0% · Q3 16.7% · Q4 1.5% · 4Q avg 15.8% |
| Percentage of long-stay residents who lose too much weight | 3.1% |
6.7%
3.6 pts better
|
5.4%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 8.3% · Q3 0.0% · Q4 1.3% · 4Q avg 3.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 37.8% |
29.6%
8.2 pts worse
|
19.6%
18.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.0% · Q2 39.2% · Q3 35.6% · Q4 37.5% · 4Q avg 37.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.0% |
17.6%
0.4 pts worse
|
16.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 15.9% · Q3 20.4% · Q4 12.0% · 4Q avg 18.0% · 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 | 10.4% |
17.3%
6.9 pts better
|
16.3%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 8.4% · Q3 11.1% · Q4 17.2% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.0% |
15.6%
8.6 pts better
|
14.9%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.2% · Q3 9.2% · Q4 11.8% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.7%
0.5 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.2% · 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 | 20.6% |
19.8%
0.8 pts worse
|
19.8%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 18.7% · Q3 17.4% · Q4 20.3% · 4Q avg 20.6% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
5.5%
0.9 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 4.0% · Q3 3.3% · Q4 4.8% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
83.8%
15.7 pts better
|
81.7%
17.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.5% · 4Q avg 99.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 25.4% |
13.9%
11.5 pts worse
|
12.0%
13.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 28.3% · Expected 12.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.8%
0.1 pts better
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 3.0% · Q4 0.0% · 4Q avg 1.7% · 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 | 28.1% |
24.5%
3.6 pts worse
|
23.9%
4.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.1% · Observed 33.3% · Expected 28.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-06-24 · Fire 2021-06-24
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2019-09-19 · Fire 2019-09-19
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-07-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-07-03
D · Potential for more than minimal harm
2025-07-03
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-07-18
D · Potential for more than minimal harm
2025-07-03
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-07-24
D · Potential for more than minimal harm
2021-06-24
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2021-07-30
F · Potential for more than minimal harm
2019-09-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-10-24
F · Potential for more than minimal harm
2019-09-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-10-24
E · Potential for more than minimal harm
2019-09-19
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-10-24
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-03
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-03
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-07-25
D · Potential for more than minimal harm
2025-07-03
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 2025-07-25
D · Potential for more than minimal harm
2025-07-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-25
F · Potential for more than minimal harm
2021-06-24
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 2021-07-30
E · Potential for more than minimal harm
2019-09-19
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2019-10-24
D · Potential for more than minimal harm
2019-09-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-10-24
D · Potential for more than minimal harm
2019-09-19
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 2019-10-24
Penalties and ownership
What sits behind the stars
Ownership
A&M Healthcare Investments LLC
5% Or Greater Direct Ownership Interest · Organization
Bush, Susan
W-2 Managing Employee · Individual
Meisels, Joseph
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Signature Healthcare at Jackson Manor Rehab and We
Annville, KY
2-star overall rating with 3-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Owsley County Health Care Center, Inc.
Booneville, KY
4-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
#3
Laurel Heights Home for the Elderly
London, KY
5-star overall rating with 5-star inspections with 9 fire-safety deficiencies in the latest cycle
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