Cycle 1
Health 2025-09-05 · Fire 2025-09-05
2 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Lexington, KY
Pine Meadows Post Acute
3-star overall rating with 3-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1608 Hill Rise Drive, Lexington, KY
(859) 254-2402
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
115
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1990-10-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 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
0.39
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.56
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.11
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.29
CMS adjusted RN staffing hours
Adjusted total hours
2.60
CMS adjusted total nurse staffing hours
Case-mix index
1.87
Higher values indicate more complex resident acuity
RN turnover
47%
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
12,482
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.03
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
1.23
Baseline 21.39% · Performance 20.86% · Measure score 1.23 · Achievement 1.23 · Improvement 0.71
Healthcare-associated infections
1.24
Baseline 8.06% · Performance 7.53% · Measure score 1.24 · Achievement 1.03 · Improvement 1.24
Total nurse turnover
2.34
Baseline 53.85% · Performance 54.10% · Measure score 2.34 · Achievement 2.34 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.54 hours · Performance 3.07 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.93% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 90 · Observed rate 14.44% · Lower 95% interval 7.52% |
| Discharge to community | 48.14% |
50.57%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 49 · Observed rate 36.73% · Lower 95% interval 35.53% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 78 · Denominator 78 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 78 |
| Discharge self-care score | 64.44% |
53.69%
10.8 pts better
|
Numerator 29 · Denominator 45 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 15 · Denominator 45 |
| Pressure ulcers or injuries, new or worsened | 2.6% |
2.29%
0.3 pts worse
|
Numerator 2 · Denominator 77 · Adjusted rate 1.81% |
| Healthcare-associated infections requiring hospitalization | 7.53% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 10.34% · Lower 95% interval 4.28% |
| Staff COVID-19 vaccination coverage | 0.72% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 138 |
| Staff flu vaccination coverage | 18.97% |
42%
23 pts worse
|
Numerator 44 · Denominator 232 |
| Discharge function score | 53.33% |
56.45%
3.1 pts worse
|
Numerator 24 · Denominator 45 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 40 · Denominator 40 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 31.48% |
25.2%
6.3 pts better
|
Numerator 17 · Denominator 54 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.9
About the same
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.2 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
2.2
0.6 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.9% |
94.3%
3.4 pts worse
|
93.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 86.1% · Q2 84.2% · Q3 96.1% · Q4 97.2% · 4Q avg 90.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.0% |
96.2%
3.2 pts worse
|
95.5%
2.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
3.8%
1.4 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.0% · Q3 2.0% · Q4 1.9% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 82.3% |
15.2%
67.1 pts worse
|
11.4%
70.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 88.4% · Q2 86.2% · Q3 77.2% · Q4 77.3% · 4Q avg 82.3% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
6.7%
1.5 pts better
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 4.8% · Q3 7.7% · Q4 2.1% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.8% |
29.6%
7.8 pts better
|
19.6%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.3% · Q2 21.9% · Q3 21.2% · Q4 21.9% · 4Q avg 21.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.7% |
17.6%
7.9 pts better
|
16.7%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 10.5% · Q3 8.8% · Q4 8.1% · 4Q avg 9.7% · 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 | 1.5% |
17.3%
15.8 pts better
|
16.3%
14.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.1% |
15.6%
10.5 pts better
|
14.9%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 5.6% · Q3 2.2% · Q4 6.2% · 4Q avg 5.1% · 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 | 1.3% |
1.7%
0.4 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 2.0% · Q4 2.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.1% |
19.8%
9.3 pts worse
|
19.8%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 31.0% · Q3 27.7% · Q4 32.4% · 4Q avg 29.1% |
| Percentage of long-stay residents with pressure ulcers | 1.9% |
5.5%
3.6 pts better
|
5.1%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 2.0% · Q3 1.2% · Q4 1.2% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.0% |
83.8%
11.2 pts better
|
81.7%
13.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.9% · Q2 94.5% · Q3 95.2% · Q4 100.0% · 4Q avg 95.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.7% |
13.9%
0.2 pts better
|
12.0%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.7% · Observed 13.2% · Expected 10.8% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.4% |
83.6%
9.8 pts better
|
79.7%
13.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.4% |
24.5%
3.1 pts better
|
23.9%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.4% · Observed 23.5% · Expected 26.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-30 · Fire 2023-11-30
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-08-12 · Fire 2022-08-12
11 health deficiencies
Top issue: Infection Control (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-09-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-10-16
D · Potential for more than minimal harm
2025-09-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-10-16
F · Potential for more than minimal harm
2022-08-12
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2022-09-16
F · Potential for more than minimal harm
2022-08-12
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2022-09-16
E · Potential for more than minimal harm
2022-08-12
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 2022-09-16
E · Potential for more than minimal harm
2022-08-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-09-16
E · Potential for more than minimal harm
2022-08-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-09-16
E · Potential for more than minimal harm
2022-08-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-09-16
E · Potential for more than minimal harm
2022-08-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-09-16
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-09-05
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 2025-10-16
D · Potential for more than minimal harm
2025-09-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-16
D · Potential for more than minimal harm
2023-11-30
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-12-23
D · Potential for more than minimal harm
2023-11-30
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 2023-12-23
D · Potential for more than minimal harm
2023-11-30
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-12-23
D · Potential for more than minimal harm
2023-11-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-23
F · Potential for more than minimal harm
2022-08-12
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 2022-09-16
F · Potential for more than minimal harm
2022-08-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-09-16
F · Potential for more than minimal harm
2022-08-12
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-09-16
E · Potential for more than minimal harm
2022-08-12
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2022-09-16
E · Potential for more than minimal harm
2022-08-12
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 2022-09-16
E · Potential for more than minimal harm
2022-08-12
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2022-09-16
E · Potential for more than minimal harm
2022-08-12
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-09-16
E · Potential for more than minimal harm
2022-08-12
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-08-12
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 2022-09-16
D · Potential for more than minimal harm
2022-08-12
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 2022-09-16
Penalties and ownership
What sits behind the stars
Ownership
Providence Group Of Kentucky LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Corporate Officer · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Hancock, Mark
Corporate Officer · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Providence Group Nh, LLC
5% Or Greater Indirect Ownership Interest · Organization
Richard, John
Contracted Managing Employee · Individual
Tippetts, Tanner
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Homestead Post Acute
Lexington, KY
3-star overall rating with 3-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Cardinal Hill Skilled Rehabilitation Unit
Lexington, KY
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Lexington Country Place
Lexington, KY
3-star overall rating with 3-star inspections with 2 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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