Cycle 1
Health 2025-06-25 · Fire 2025-06-25
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Somerset, KY
Somerset Nursing and Rehabilitation Facility
2-star overall rating with 4-star inspections with 3 fire-safety deficiencies in the latest cycle
106 Gover Street, Somerset, KY
(606) 679-8331
Overall
2 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
123
Certified beds
Average residents
116
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Bluegrass Health Ky
Operator or chain grouping
Approved since
1990-11-15
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
0.32
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.56
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.65
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.09
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.26
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.13
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.26
CMS adjusted RN staffing hours
Adjusted total hours
2.96
CMS adjusted total nurse staffing hours
Case-mix index
1.69
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,400
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.88
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.12% · Performance 22.39% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 9.29% · Performance 9.31% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.75
Baseline 37.60% · Performance 36.08% · Measure score 6.75 · Achievement 6.75 · Improvement 0.69
Adjusted total nurse staffing
0
Baseline 3.15 hours · Performance 3 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.61% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 104 · Observed rate 7.69% · Lower 95% interval 6.33% |
| Discharge to community | 59.17% |
50.57%
8.6 pts better
|
No Different than the National Rate · Eligible stays 81 · Observed rate 54.32% · Lower 95% interval 48.43% |
| Medicare spending per beneficiary | 1.66 |
1.02
0.6 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 89 · Denominator 89 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 89 |
| Discharge self-care score | 32.2% |
53.69%
21.5 pts worse
|
Numerator 19 · Denominator 59 |
| Discharge mobility score | 27.12% |
50.94%
23.8 pts worse
|
Numerator 16 · Denominator 59 |
| Pressure ulcers or injuries, new or worsened | 6.74% |
2.29%
4.5 pts worse
|
Numerator 6 · Denominator 89 · Adjusted rate 6.01% |
| Healthcare-associated infections requiring hospitalization | 9.31% |
7.12%
2.2 pts worse
|
No Different than the National Rate · Eligible stays 89 · Observed rate 12.36% · Lower 95% interval 6.14% |
| Staff COVID-19 vaccination coverage | 1.31% |
8.2%
6.9 pts worse
|
Numerator 2 · Denominator 153 |
| Staff flu vaccination coverage | 19.05% |
42%
22.9 pts worse
|
Numerator 32 · Denominator 168 |
| Discharge function score | 33.9% |
56.45%
22.6 pts worse
|
Numerator 20 · Denominator 59 |
| Transfer of health information to provider | 97.78% |
95.95%
1.8 pts better
|
Numerator 44 · Denominator 45 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 25.53% |
25.2%
0.3 pts better
|
Numerator 12 · Denominator 47 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.3 |
1.9
1.4 pts worse
|
1.9
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 3.4 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
2.2
0.3 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.6 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.3%
5.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.3% |
96.2%
1.1 pts better
|
95.5%
1.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
3.8%
About the same
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 4.0% · Q3 3.9% · Q4 3.7% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 78.2% |
15.2%
63 pts worse
|
11.4%
66.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 77.6% · Q2 78.3% · Q3 82.8% · Q4 74.7% · 4Q avg 78.2% |
| Percentage of long-stay residents who lose too much weight | 8.1% |
6.7%
1.4 pts worse
|
5.4%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 11.2% · Q3 9.1% · Q4 5.5% · 4Q avg 8.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 39.9% |
29.6%
10.3 pts worse
|
19.6%
20.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.5% · Q2 39.8% · Q3 40.4% · Q4 42.3% · 4Q avg 39.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.9% |
17.6%
4.3 pts worse
|
16.7%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.0% · Q2 26.0% · Q3 18.9% · Q4 19.5% · 4Q avg 21.9% · 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 | 25.7% |
17.3%
8.4 pts worse
|
16.3%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.4% · Q2 38.6% · Q3 19.3% · Q4 12.8% · 4Q avg 25.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.2% |
15.6%
7.6 pts worse
|
14.9%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.4% · Q2 32.5% · Q3 16.5% · Q4 15.3% · 4Q avg 23.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.7%
0.1 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.7%
1 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 1.0% · Q4 1.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.8% |
19.8%
2 pts worse
|
19.8%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 15.6% · Q3 23.6% · Q4 25.1% · 4Q avg 21.8% |
| Percentage of long-stay residents with pressure ulcers | 7.3% |
5.5%
1.8 pts worse
|
5.1%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 5.3% · Q3 6.8% · Q4 6.4% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
83.8%
15.9 pts better
|
81.7%
18 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.9% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.7% |
13.9%
2.8 pts worse
|
12.0%
4.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.7% · Observed 15.2% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.9% |
1.8%
4.1 pts worse
|
1.6%
4.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 6.9% · Q3 3.7% · Q4 3.9% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.5% |
83.6%
10.9 pts better
|
79.7%
14.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.2% |
24.5%
0.7 pts worse
|
23.9%
1.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.2% · Observed 27.2% · Expected 25.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-08-11 · Fire 2021-08-11
6 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-11-16 · Fire 2019-11-16
11 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-06-25
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 2025-07-09
D · Potential for more than minimal harm
2025-06-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-09
D · Potential for more than minimal harm
2025-06-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-07-09
D · Potential for more than minimal harm
2019-11-16
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 2019-12-04
D · Potential for more than minimal harm
2019-11-16
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 2019-11-22
Inspection history
Recent health citations
F · Potential for more than minimal harm
2021-08-11
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2021-09-24
E · Potential for more than minimal harm
2021-08-11
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 2021-09-24
E · Potential for more than minimal harm
2021-08-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-09-24
E · Potential for more than minimal harm
2021-08-11
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 2021-09-24
D · Potential for more than minimal harm
2021-08-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-09-24
D · Potential for more than minimal harm
2021-08-11
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2021-09-24
G · Actual harm
2019-11-16
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 2020-02-01
G · Actual harm
2019-11-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2020-02-01
E · Potential for more than minimal harm
2019-11-16
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2020-02-01
E · Potential for more than minimal harm
2019-11-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2020-02-01
E · Potential for more than minimal harm
2019-11-16
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2020-01-08
E · Potential for more than minimal harm
2019-11-16
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2020-02-01
D · Potential for more than minimal harm
2019-11-16
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2020-02-01
D · Potential for more than minimal harm
2019-11-16
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 2020-02-01
D · Potential for more than minimal harm
2019-11-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-12-09
D · Potential for more than minimal harm
2019-11-16
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-12-09
D · Potential for more than minimal harm
2019-11-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-02-01
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
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
Ridner, Tammy
Operational/Managerial Control · Individual
Somerset Realty LLC
5% Or Greater Mortgage Interest · Organization
Valley Stream Operator I LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Lake Cumberland Regional Hospital Scu
Somerset, KY
4-star overall rating with 5-star inspections
#2
Somerwoods Rehabilitation and Healthcare Center
Somerset, KY
2-star overall rating with 3-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Cumberland Nursing and Rehabilitation Center
Somerset, KY
2-star overall rating with 2-star inspections with $6,991 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Jump out