Cycle 1
Health 2025-02-27 · Fire 2025-02-27
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Whitesburg, KY
Letcher Manor
2-star overall rating with 3-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
73 Piedmont Drive, Whitesburg, KY
(606) 633-1434
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
142
Certified beds
Average residents
118
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bluegrass Health Ky
Operator or chain grouping
Approved since
1989-10-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
15 facilities
Chain averages 3 overall / 3 health / 1 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
0.40
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.73
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
3.42
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.14
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.34
CMS adjusted RN staffing hours
Adjusted total hours
2.84
CMS adjusted total nurse staffing hours
Case-mix index
1.65
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.21
Composite VBP score used to determine payment impact.
Payment multiplier
0.9889
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.40
Baseline 28.00% · Performance 21.52% · Measure score 5.40 · Achievement 0 · Improvement 5.40
Healthcare-associated infections
0
Baseline 9.20% · Performance 11.69% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
7.27
Baseline 50.48% · Performance 33.98% · Measure score 7.27 · Achievement 7.27 · Improvement 5.94
Adjusted total nurse staffing
1.41
Baseline 2.51 hours · Performance 3.14 hours · Measure score 1.41 · Achievement 0 · Improvement 1.41
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.47% |
10.72%
2.8 pts worse
|
No Different than the National Rate · Eligible stays 71 · Observed rate 25.35% · Lower 95% interval 9.86% |
| Discharge to community | 38.77% |
50.57%
11.8 pts worse
|
No Different than the National Rate · Eligible stays 82 · Observed rate 26.83% · Lower 95% interval 29.93% |
| Medicare spending per beneficiary | 1.57 |
1.02
0.6 pts worse
|
|
| Drug regimen review with follow-up | 97.1% |
95.27%
1.8 pts better
|
Numerator 67 · Denominator 69 |
| Falls with major injury | 1.45% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 69 |
| Discharge self-care score | 32.43% |
53.69%
21.3 pts worse
|
Numerator 12 · Denominator 37 |
| Discharge mobility score | 45.95% |
50.94%
5 pts worse
|
Numerator 17 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 4.35% |
2.29%
2.1 pts worse
|
Numerator 3 · Denominator 69 · Adjusted rate 2.98% |
| Healthcare-associated infections requiring hospitalization | 11.69% |
7.12%
4.6 pts worse
|
Worse than the National Rate · Eligible stays 61 · Observed rate 21.31% · Lower 95% interval 7.18% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 130 |
| Staff flu vaccination coverage | 5.92% |
42%
36.1 pts worse
|
Numerator 10 · Denominator 169 |
| Discharge function score | 43.24% |
56.45%
13.2 pts worse
|
Numerator 16 · Denominator 37 |
| Transfer of health information to provider | 96.43% |
95.95%
0.5 pts better
|
Numerator 27 · Denominator 28 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 21 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 37 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.9
0.6 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.3 |
2.2
2.1 pts worse
|
1.8
2.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.3 · Observed 4.3 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.7% |
94.3%
1.6 pts worse
|
93.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 84.5% · Q2 91.0% · Q3 95.5% · Q4 100.0% · 4Q avg 92.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.3% |
96.2%
2.1 pts better
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
3.8%
0.7 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 5.4% · Q3 4.5% · Q4 4.6% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.2% |
15.2%
8 pts better
|
11.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 15.8% · Q4 10.9% · 4Q avg 7.2% |
| Percentage of long-stay residents who lose too much weight | 8.2% |
6.7%
1.5 pts worse
|
5.4%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 8.4% · Q3 6.7% · Q4 9.8% · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.2% |
29.6%
2.6 pts worse
|
19.6%
12.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.7% · Q2 31.8% · Q3 32.7% · Q4 30.8% · 4Q avg 32.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.7% |
17.6%
7.1 pts worse
|
16.7%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 25.6% · Q3 25.0% · Q4 23.2% · 4Q avg 24.7% · 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 | 15.2% |
17.3%
2.1 pts better
|
16.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 19.1% · Q3 9.1% · Q4 22.5% · 4Q avg 15.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.2% |
15.6%
1.4 pts better
|
14.9%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 16.3% · Q3 10.8% · Q4 15.1% · 4Q avg 14.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.7%
About the same
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · 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 | 18.7% |
19.8%
1.1 pts better
|
19.8%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 18.4% · Q3 10.9% · Q4 17.8% · 4Q avg 18.7% |
| Percentage of long-stay residents with pressure ulcers | 7.7% |
5.5%
2.2 pts worse
|
5.1%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 7.4% · Q3 9.3% · Q4 6.5% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.3% |
83.8%
3.5 pts better
|
81.7%
5.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.8% · Q2 84.9% · Q3 88.1% · Q4 89.6% · 4Q avg 87.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.1% |
13.9%
5.8 pts better
|
12.0%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.1% · Observed 9.1% · Expected 12.5% · 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 · Q1 5.6% · Q2 4.3% · Q3 0.0% · Q4 3.8% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 64.0% |
83.6%
19.6 pts worse
|
79.7%
15.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 64.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.7% |
24.5%
0.8 pts better
|
23.9%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.7% · Observed 27.3% · Expected 27.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-05 · Fire 2024-04-05
3 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2019-11-07 · Fire 2019-11-07
4 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-19
D · Potential for more than minimal harm
2025-02-27
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-03-19
F · Potential for more than minimal harm
2024-04-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-02
F · Potential for more than minimal harm
2024-04-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-05-02
F · Potential for more than minimal harm
2024-04-05
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-05-02
F · Potential for more than minimal harm
2024-04-05
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-05-02
E · Potential for more than minimal harm
2024-04-05
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 2024-05-02
E · Potential for more than minimal harm
2024-04-05
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-05-02
E · Potential for more than minimal harm
2024-04-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-05-02
E · Potential for more than minimal harm
2024-04-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-02
D · Potential for more than minimal harm
2024-04-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-05-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-27
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 2025-03-18
D · Potential for more than minimal harm
2025-02-27
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 2025-03-18
D · Potential for more than minimal harm
2025-02-27
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 2025-03-18
D · Potential for more than minimal harm
2025-02-27
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 2025-03-18
D · Potential for more than minimal harm
2025-02-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-18
E · Potential for more than minimal harm
2024-04-05
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-05-03
D · Potential for more than minimal harm
2024-04-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-05-03
E · Potential for more than minimal harm
2019-11-07
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 2019-11-28
D · Potential for more than minimal harm
2019-11-07
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2019-11-28
D · Potential for more than minimal harm
2019-11-07
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2019-11-28
D · Potential for more than minimal harm
2019-11-07
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-11-28
Penalties and ownership
What sits behind the stars
Ownership
Landa, Benjamin
5% Or Greater Direct Ownership Interest · Individual
Ky Equity Partners LLC
5% Or Greater Direct Ownership Interest · Organization
Grinspan, Eli
5% Or Greater Direct Ownership Interest · Individual
Kennedy Ky Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Fischl, Mayer
5% Or Greater Direct Ownership Interest · Individual
Bowling, Amanda
Operational/Managerial Control · Individual
Djlm Realty LLC
5% Or Greater Mortgage Interest · Organization
Fischl, Mayer
Operational/Managerial Control · Individual
Fischl, Mayer
Corporate Officer · Individual
Greystone Servicing Company, LLC, A Delaware Limited Liability Company
5% Or Greater Mortgage Interest · Organization
Grinspan, Eli
Operational/Managerial Control · Individual
Grinspan, Eli
Corporate Officer · Individual
Valley Stream Operator I LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Norton Community Hospital SNF Unit
Norton, VA
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Tri Cities Rehabilitation and Healthcare Center
Cumberland, KY
3-star overall rating with 2-star inspections with $5,346 in total fines with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Heritage Hall Big Stone Gap
Big Stone Gap, VA
3-star overall rating with 3-star inspections with $71,620 in total fines with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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