Frenchburg, KY

Menifee Meadows Nursing & Rehab LLC

2-star overall rating with 2-star inspections with 1 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle

195 Berryman Road, Frenchburg, KY

(606) 768-9001

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

60

Certified beds

Average residents

51

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1996-05-14

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

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

0.61

Registered nurse staffing · state 0.77 · national 0.68

LPN hours / resident day

0.70

Licensed practical nurse staffing · state 0.81 · national 0.87

Aide hours / resident day

2.60

Nurse aide staffing · state 2.43 · national 2.35

Total nurse hours

3.91

All reported nurse hours · state 4.01 · national 3.89

Licensed hours

1.31

RN + LPN hours · state 1.58 · national 1.54

Weekend hours

3.61

Weekend nurse staffing · state 3.50 · national 3.43

Weekend RN hours

0.43

Weekend registered nurse coverage · state 0.52 · national 0.47

Physical therapist

0.21

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.73

CMS adjusted RN staffing hours

Adjusted total hours

4.66

CMS adjusted total nurse staffing hours

Case-mix index

1.15

Higher values indicate more complex resident acuity

RN turnover

57%

Annual RN turnover · state 43% · national 45%

Total nurse turnover

54%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

7,123

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

30.67

Composite VBP score used to determine payment impact.

Payment multiplier

0.9861

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

0

Baseline 46.51% · Performance 69.86% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

6.13

Baseline 4.02 hours · Performance 4.82 hours · Measure score 6.13 · Achievement 6.13 · Improvement 4.07

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	Not Available	1.02	Too few residents or stays to report publicly.
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 11 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 11 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	4.35%	8.2% 3.8 pts worse	Numerator 4 · Denominator 92
Staff flu vaccination coverage	37.7%	42% 4.3 pts worse	Numerator 46 · Denominator 122
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.8	1.9 1.1 pts better	1.9 1.1 pts better	Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.5 · 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	95.9%	94.3% 1.6 pts better	93.4% 2.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 83.3% · Q2 98.0% · Q3 100.0% · Q4 100.0% · 4Q avg 95.9%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	94.5%	96.2% 1.7 pts worse	95.5% 1 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 94.5%
Percentage of long-stay residents experiencing one or more falls with major injury	0.5%	3.8% 3.3 pts better	3.3% 2.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.0%	15.2% 15.2 pts better	11.4% 11.4 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 who lose too much weight	4.2%	6.7% 2.5 pts better	5.4% 1.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 7.7% · Q4 8.0% · 4Q avg 4.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	34.7%	29.6% 5.1 pts worse	19.6% 15.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 34.7% · Q3 26.9% · Q4 44.0% · 4Q avg 34.7%
Percentage of long-stay residents who received an antipsychotic medication	34.4%	17.6% 16.8 pts worse	16.7% 17.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 36.4% · Q2 30.8% · Q3 31.7% · Q4 39.0% · 4Q avg 34.4% · 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	31.6%	17.3% 14.3 pts worse	16.3% 15.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 39.0% · Q3 18.9% · Q4 37.2% · 4Q avg 31.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	30.2%	15.6% 14.6 pts worse	14.9% 15.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 29.4% · Q3 25.6% · Q4 47.6% · 4Q avg 30.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	3.4%	0.7% 2.7 pts worse	1.0% 2.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 2.4% · Q3 4.2% · Q4 2.0% · 4Q avg 3.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	4.7%	1.7% 3 pts worse	1.7% 3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 2.0% · Q3 5.8% · Q4 2.0% · 4Q avg 4.7% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	21.1%	19.8% 1.3 pts worse	19.8% 1.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 19.1% · Q3 19.4% · Q4 23.8% · 4Q avg 21.1%
Percentage of long-stay residents with pressure ulcers	1.7%	5.5% 3.8 pts better	5.1% 3.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 0.0% · Q3 2.2% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	82.6%	83.8% 1.2 pts worse	81.7% 0.9 pts better	Short Stay · 2024Q4-2025Q3 · Q1 72.4% · Q2 90.9% · 4Q avg 82.6%
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.8% 1.8 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	81.8%	83.6% 1.8 pts worse	79.7% 2.1 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 81.8%

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-12-20 · Fire 2024-12-20

1 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

9 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 2 Health 2020-01-09 · Fire 2020-01-09

6 health deficiencies

Top issue: Infection Control (2 deficiencies)

1 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Cycle 3 Health 2018-10-25 · Fire 2018-10-25

11 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

1 fire-safety deficiencies

Top issue: Emergency Preparedness (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-12-20

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2025-01-24

F · Potential for more than minimal harm 2024-12-20

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2025-01-24

F · Potential for more than minimal harm 2024-12-20

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 2025-01-24

F · Potential for more than minimal harm 2024-12-20

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-01-24

F · Potential for more than minimal harm 2024-12-20

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2025-01-24

E · Potential for more than minimal harm 2024-12-20

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 2025-01-24

E · Potential for more than minimal harm 2024-12-20

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-01-24

E · Potential for more than minimal harm 2024-12-20

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-01-24

D · Potential for more than minimal harm 2024-12-20

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2025-01-24

F · Potential for more than minimal harm 2020-01-09

K771 · Miscellaneous Deficiencies

Fire Safety

Ensure that smoke control systems are tested and documented in accordance with established engineering principles.

Corrected 2020-01-14

F · Potential for more than minimal harm 2018-10-25

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2018-11-16

Inspection history

Recent health citations

E · Potential for more than minimal harm 2024-12-20

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 2025-01-16

G · Actual harm 2023-07-28

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 2023-08-15

G · Actual harm 2023-07-28

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 2023-08-15

D · Potential for more than minimal harm 2023-07-28

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 2023-08-15