Cycle 1
Health 2024-10-03 · Fire 2024-10-03
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Flemingsburg, KY
Pioneer Trace Group LLC
1-star overall rating with 2-star inspections with $27,493 in total fines with 4 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
115 Pioneer Trace, Flemingsburg, KY
(606) 845-2131
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
92
Certified beds
Average residents
79
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1991-10-30
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
0.42
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.12
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.43
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
3.06
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.29
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
0.39
CMS adjusted RN staffing hours
Adjusted total hours
3.19
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,831
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.37
Composite VBP score used to determine payment impact.
Payment multiplier
0.9829
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.41% · Performance 22.05% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.77
Baseline 5.78% · Performance 7.01% · Measure score 2.77 · Achievement 2.77 · Improvement 0
Total nurse turnover
4.90
Baseline 33.90% · Performance 43.66% · Measure score 4.90 · Achievement 4.90 · Improvement 0
Adjusted total nurse staffing
1.28
Baseline 3.16 hours · Performance 3.44 hours · Measure score 1.28 · Achievement 1.28 · Improvement 0.59
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.49% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 43 · Observed rate 18.6% · Lower 95% interval 7.95% |
| Discharge to community | 34.14% |
50.57%
16.4 pts worse
|
Worse than the National Rate · Eligible stays 31 · Observed rate 22.58% · Lower 95% interval 24.33% |
| Medicare spending per beneficiary | 1.42 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 98.08% |
95.27%
2.8 pts better
|
Numerator 51 · Denominator 52 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 52 |
| Discharge self-care score | 15.15% |
53.69%
38.5 pts worse
|
Numerator 5 · Denominator 33 |
| Discharge mobility score | 12.12% |
50.94%
38.8 pts worse
|
Numerator 4 · Denominator 33 |
| Pressure ulcers or injuries, new or worsened | 13.46% |
2.29%
11.2 pts worse
|
Numerator 7 · Denominator 52 · Adjusted rate 10.98% |
| Healthcare-associated infections requiring hospitalization | 7.01% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 42 · Observed rate 7.14% · Lower 95% interval 3.77% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 102 |
| Staff flu vaccination coverage | 5.29% |
42%
36.7 pts worse
|
Numerator 9 · Denominator 170 |
| Discharge function score | 24.24% |
56.45%
32.2 pts worse
|
Numerator 8 · Denominator 33 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 30% |
25.2%
4.8 pts better
|
Numerator 6 · Denominator 20 |
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 2.3 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 5.2 |
2.2
3 pts worse
|
1.8
3.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 5.2 · Observed 5.2 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
94.3%
5 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.7% · Q4 98.7% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.2% |
96.2%
About the same
|
95.5%
0.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.7% |
3.8%
0.1 pts better
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.0% · Q3 2.6% · Q4 3.9% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.2% |
15.2%
9 pts better
|
11.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 4.6% · Q3 7.6% · Q4 7.4% · 4Q avg 6.2% |
| Percentage of long-stay residents who lose too much weight | 8.0% |
6.7%
1.3 pts worse
|
5.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 8.6% · Q3 9.1% · Q4 6.9% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.2% |
29.6%
3.4 pts better
|
19.6%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.9% · Q2 25.0% · Q3 23.2% · Q4 28.8% · 4Q avg 26.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.2% |
17.6%
5.6 pts worse
|
16.7%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.0% · Q2 24.5% · Q3 22.0% · Q4 18.5% · 4Q avg 23.2% · 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 | 32.1% |
17.3%
14.8 pts worse
|
16.3%
15.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.7% · Q2 42.5% · Q3 15.0% · Q4 39.6% · 4Q avg 32.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.7% |
15.6%
17.1 pts worse
|
14.9%
17.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.3% · Q2 47.1% · Q3 21.9% · Q4 29.0% · 4Q avg 32.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.4% |
0.7%
1.7 pts worse
|
1.0%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 4.2% · Q3 2.0% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
1.7%
0.4 pts worse
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 1.4% · Q4 4.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.5% |
19.8%
4.7 pts worse
|
19.8%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q2 26.9% · Q3 15.9% · Q4 30.9% · 4Q avg 24.5% |
| Percentage of long-stay residents with pressure ulcers | 8.8% |
5.5%
3.3 pts worse
|
5.1%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 8.6% · Q3 13.9% · Q4 4.4% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.2% |
83.8%
0.6 pts worse
|
81.7%
1.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 73.5% · Q2 83.9% · Q3 81.2% · Q4 96.4% · 4Q avg 83.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.5% |
13.9%
0.6 pts worse
|
12.0%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.5% · Observed 13.8% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 6.2% |
1.8%
4.4 pts worse
|
1.6%
4.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 68.8% |
83.6%
14.8 pts worse
|
79.7%
10.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 68.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.5% |
24.5%
1 pts worse
|
23.9%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.5% · Observed 24.1% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-11-14 · Fire 2019-11-14
2 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2018-09-13 · Fire 2018-09-13
10 health deficiencies
Top issue: Infection Control (2 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-03
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2024-10-19
F · Potential for more than minimal harm
2024-10-03
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-10-19
F · Potential for more than minimal harm
2024-10-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-25
F · Potential for more than minimal harm
2024-10-03
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 2024-11-30
F · Potential for more than minimal harm
2024-10-03
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-11-30
F · Potential for more than minimal harm
2024-10-03
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-11-30
E · Potential for more than minimal harm
2024-10-03
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-10-19
E · Potential for more than minimal harm
2024-10-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-01-17
D · Potential for more than minimal harm
2024-10-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-19
D · Potential for more than minimal harm
2024-10-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-19
D · Potential for more than minimal harm
2024-10-03
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 2024-10-24
D · Potential for more than minimal harm
2019-11-14
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 2019-12-18
D · Potential for more than minimal harm
2019-11-14
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-12-18
D · Potential for more than minimal harm
2019-11-14
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 2019-12-18
D · Potential for more than minimal harm
2019-11-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-12-18
D · Potential for more than minimal harm
2019-11-14
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 2019-12-18
E · Potential for more than minimal harm
2018-09-13
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2018-10-17
D · Potential for more than minimal harm
2018-09-13
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2018-10-17
C · Minimal harm
2018-09-13
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2018-10-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-08
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Not marked corrected
F · Potential for more than minimal harm
2024-10-03
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2024-11-05
F · Potential for more than minimal harm
2024-10-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-01
E · Potential for more than minimal harm
2024-10-03
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 2025-01-01
D · Potential for more than minimal harm
2019-11-14
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 2019-12-18
D · Potential for more than minimal harm
2019-11-14
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 2019-12-18
E · Potential for more than minimal harm
2018-09-13
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2018-10-17
E · Potential for more than minimal harm
2018-09-13
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2018-10-17
E · Potential for more than minimal harm
2018-09-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-10-17
E · Potential for more than minimal harm
2018-09-13
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2018-10-17
D · Potential for more than minimal harm
2018-09-13
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2018-10-17
D · Potential for more than minimal harm
2018-09-13
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 2018-10-17
D · Potential for more than minimal harm
2018-09-13
F659 · Resident Assessment and Care Planning Deficiencies
Health
Provide care by qualified persons according to each resident's written plan of care.
Corrected 2018-10-17
D · Potential for more than minimal harm
2018-09-13
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2018-10-17
D · Potential for more than minimal harm
2018-09-13
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 2018-10-17
D · Potential for more than minimal harm
2018-09-13
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 2018-10-17
Penalties and ownership
What sits behind the stars
$5,346
2024-10-03
Fine
Fine · fine $5,346
Fine
$5,346
2024-10-03
Fine
Fine · fine $5,346
Fine
$16,801
2024-10-03
Fine
Fine · fine $16,801
Fine
$0
2024-10-03
Payment Denial
Payment Denial · denial start 2024-12-20 · 28 days
28 day denial
Ownership
Frances, Jay
5% Or Greater Direct Ownership Interest · Individual
Smith, Kimberly
5% Or Greater Direct Ownership Interest · Individual
Frances, Jay
Operational/Managerial Control · Individual
Frances, Jay
Corporate Officer · Individual
Legacy Health Services Inc
Operational/Managerial Control · Organization
Mcintyre, Amanda
Operational/Managerial Control · Individual
Smith, Kimberly
Operational/Managerial Control · Individual
Smith, Kimberly
Corporate Officer · Individual
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#2
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0-star overall rating with 0-star inspections
#3
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2-star overall rating with 2-star inspections with abuse icon flag with $8,788 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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