Cycle 1
Health 2025-08-22 · Fire 2025-08-22
2 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Nicholasville, KY
Nicholasville Nursing and Rehabilitation
1-star overall rating with 2-star inspections with $16,104 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
100 Sparks Avenue, Nicholasville, KY
(859) 885-4171
Overall
1 / 5
CMS overall stars
Health inspections
2 / 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
73
Certified beds
Average residents
66
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
David Marx
Operator or chain grouping
Approved since
1990-11-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 2 overall / 3 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
0.50
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.07
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.26
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.19
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
2.96
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.28
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
3.00
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
83%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
82%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,417
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.39
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.92% · Performance 22.77% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.21
Baseline 8.40% · Performance 6.80% · Measure score 4.21 · Achievement 3.47 · Improvement 4.21
Total nurse turnover
0
Baseline 73.68% · Performance 79.77% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.75
Baseline 2.99 hours · Performance 3.29 hours · Measure score 0.75 · Achievement 0.75 · Improvement 0.58
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.65% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 15% · Lower 95% interval 7.68% |
| Discharge to community | 51.05% |
50.57%
0.5 pts better
|
No Different than the National Rate · Eligible stays 51 · Observed rate 43.14% · Lower 95% interval 36.19% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 29 · Denominator 29 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 29 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 13.79% |
2.29%
11.5 pts worse
|
Numerator 4 · Denominator 29 · Adjusted rate 14.78% |
| Healthcare-associated infections requiring hospitalization | 6.8% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 5.71% · Lower 95% interval 3.27% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 47 |
| Staff flu vaccination coverage | 15% |
42%
27 pts worse
|
Numerator 15 · Denominator 100 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · 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 | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · 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 | 1.1 |
1.9
0.8 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.0 · Expected 1.7 · 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 2.0 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 82.0% |
94.3%
12.3 pts worse
|
93.4%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 83.1% · Q2 84.7% · Q3 82.0% · Q4 78.3% · 4Q avg 82.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.5% |
96.2%
3.7 pts worse
|
95.5%
3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.1% |
3.8%
3.3 pts worse
|
3.3%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 6.8% · Q3 6.6% · Q4 8.3% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 27.9% |
15.2%
12.7 pts worse
|
11.4%
16.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.7% · Q2 20.4% · Q3 26.8% · Q4 31.0% · 4Q avg 27.9% |
| Percentage of long-stay residents who lose too much weight | 17.0% |
6.7%
10.3 pts worse
|
5.4%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.1% · Q2 10.3% · Q3 15.3% · Q4 14.3% · 4Q avg 17.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.5% |
29.6%
14.1 pts better
|
19.6%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 15.5% · Q3 16.9% · Q4 17.2% · 4Q avg 15.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.9% |
17.6%
8.7 pts better
|
16.7%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 10.6% · Q3 4.0% · Q4 2.2% · 4Q avg 8.9% · 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 | 0.0% |
17.3%
17.3 pts better
|
16.3%
16.3 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 whose need for help with daily activities has increased | 2.3% |
15.6%
13.3 pts better
|
14.9%
12.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 3.6% · Q3 1.8% · Q4 0.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.7%
1.3 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.9% |
19.8%
7.1 pts worse
|
19.8%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.7% · Q2 24.1% · Q3 27.2% · Q4 31.6% · 4Q avg 26.9% |
| Percentage of long-stay residents with pressure ulcers | 10.8% |
5.5%
5.3 pts worse
|
5.1%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 13.4% · Q3 3.9% · Q4 9.0% · 4Q avg 10.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 31.8% |
83.8%
52 pts worse
|
81.7%
49.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 44.3% · Q3 42.9% · Q4 24.1% · 4Q avg 31.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.0% |
13.9%
8.1 pts worse
|
12.0%
10 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.0% · Observed 21.7% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.0% |
1.8%
1.2 pts worse
|
1.6%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.3% · Q4 10.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 58.7% |
83.6%
24.9 pts worse
|
79.7%
21 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 58.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 39.7% |
24.5%
15.2 pts worse
|
23.9%
15.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 39.7% · Observed 39.1% · Expected 23.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-12 · Fire 2024-09-12
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2019-08-29 · Fire 2019-08-29
17 health deficiencies
Top issue: Resident Assessment and Care Planning (8 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-08-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-09-18
D · Potential for more than minimal harm
2025-08-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-09-18
F · Potential for more than minimal harm
2024-09-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-06
F · Potential for more than minimal harm
2024-09-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-06
F · Potential for more than minimal harm
2024-09-12
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-10-06
E · Potential for more than minimal harm
2024-09-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-10-06
D · Potential for more than minimal harm
2024-09-12
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 2024-10-06
D · Potential for more than minimal harm
2024-09-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-06
F · Potential for more than minimal harm
2019-08-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-10-11
E · Potential for more than minimal harm
2019-08-29
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2019-10-11
D · Potential for more than minimal harm
2019-08-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-10-11
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-22
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 2025-09-18
E · Potential for more than minimal harm
2025-08-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-18
F · Potential for more than minimal harm
2024-09-12
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 2024-10-16
F · Potential for more than minimal harm
2024-09-12
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 2024-10-16
F · Potential for more than minimal harm
2024-09-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-16
E · Potential for more than minimal harm
2024-09-12
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 2024-10-16
E · Potential for more than minimal harm
2024-09-12
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-09-12
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 2024-10-16
D · Potential for more than minimal harm
2024-09-12
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 2024-10-16
D · Potential for more than minimal harm
2024-09-12
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 2024-10-16
D · Potential for more than minimal harm
2024-09-12
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 2024-10-16
D · Potential for more than minimal harm
2024-09-12
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-09-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-09-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-16
E · Potential for more than minimal harm
2023-07-13
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 2023-08-01
D · Potential for more than minimal harm
2023-07-13
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-07-13
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 2023-08-01
D · Potential for more than minimal harm
2023-07-13
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-08-01
G · Actual harm
2023-05-05
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 2023-08-01
G · Actual harm
2023-05-05
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 2023-06-21
E · Potential for more than minimal harm
2023-05-05
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 2023-08-01
D · Potential for more than minimal harm
2023-05-05
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 2023-06-21
D · Potential for more than minimal harm
2023-05-05
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-05-05
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-08-01
E · Potential for more than minimal harm
2019-08-29
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 2019-10-11
E · Potential for more than minimal harm
2019-08-29
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 2019-10-11
D · Potential for more than minimal harm
2019-08-29
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2019-10-11
D · Potential for more than minimal harm
2019-08-29
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 2019-10-11
D · Potential for more than minimal harm
2019-08-29
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 2019-10-11
D · Potential for more than minimal harm
2019-08-29
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 2019-10-11
D · Potential for more than minimal harm
2019-08-29
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2019-10-11
Penalties and ownership
What sits behind the stars
$3,728
2023-05-05
Fine
Fine · fine $3,728
Fine
$3,728
2023-05-05
Fine
Fine · fine $3,728
Fine
$4,324
2023-05-05
Fine
Fine · fine $4,324
Fine
$4,324
2023-05-05
Fine
Fine · fine $4,324
Fine
$0
2023-05-05
Payment Denial
Payment Denial · denial start 2023-06-17 · 45 days
45 day denial
Ownership
Marx, David
5% Or Greater Indirect Ownership Interest · Individual
Nicholasville Nursing And Rehabilitation Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
100 Sparks Ave SNF Realty LLC
Operational/Managerial Control · Organization
Alexander, James
Operational/Managerial Control · Individual
Bluegrass Consulting Group LLC
Operational/Managerial Control · Organization
Chamberlain, Margaret
Operational/Managerial Control · Individual
Davis, Lisa
Operational/Managerial Control · Individual
Faughn, Laura
Operational/Managerial Control · Individual
Marx, David
Operational/Managerial Control · Individual
Pruitt, Paul
Operational/Managerial Control · Individual
Rewa, Angela
Operational/Managerial Control · Individual
Russell, Robert
Operational/Managerial Control · Individual
Shatrov, Anzhelika
Operational/Managerial Control · Individual
Wolfe, Eric
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Thomson-Hood Veterans Center
Wilmore, KY
5-star overall rating with 3-star inspections with 3 recent health deficiencies
#2
The Willows at Fritz Farm
Lexington, KY
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Sayre Christian Village Nursing Home
Lexington, KY
2-star overall rating with 3-star inspections with $7,901 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Jump out