Cycle 1
Health 2025-08-15 · Fire 2025-08-15
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Lebanon, KY
The Village of Lebanon II, LLC
2-star overall rating with 3-star inspections with $45,335 in total fines with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
105 Village Way, Lebanon, KY
(270) 692-9000
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
64
Certified beds
Average residents
51
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1997-10-02
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
0.54
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.01
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
3.07
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
4.62
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.00
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.33
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
4.28
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,203
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
58.83
Composite VBP score used to determine payment impact.
Payment multiplier
1.0140
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.99
Baseline 20.31% · Performance 18.19% · Measure score 6.99 · Achievement 6.99 · Improvement 5.96
Healthcare-associated infections
5.87
Baseline 6.09% · Performance 6.08% · Measure score 5.87 · Achievement 5.87 · Improvement 0
Total nurse turnover
4.97
Performance 43.37% · Measure score 4.97 · Achievement 4.97 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
5.70
Baseline 4.22 hours · Performance 4.7 hours · Measure score 5.70 · Achievement 5.70 · Improvement 2.59
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.52% |
10.72%
2.2 pts better
|
No Different than the National Rate · Eligible stays 88 · Observed rate 2.27% · Lower 95% interval 6.09% |
| Discharge to community | 57.69% |
50.57%
7.1 pts better
|
No Different than the National Rate · Eligible stays 78 · Observed rate 58.97% · Lower 95% interval 49.31% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 59 · Denominator 59 |
| Falls with major injury | 1.69% |
0.77%
0.9 pts worse
|
Numerator 1 · Denominator 59 |
| Discharge self-care score | 28.95% |
53.69%
24.7 pts worse
|
Numerator 11 · Denominator 38 |
| Discharge mobility score | 26.32% |
50.94%
24.6 pts worse
|
Numerator 10 · Denominator 38 |
| Pressure ulcers or injuries, new or worsened | 5.08% |
2.29%
2.8 pts worse
|
Numerator 3 · Denominator 59 · Adjusted rate 3.97% |
| Healthcare-associated infections requiring hospitalization | 6.08% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 51 · Observed rate 1.96% · Lower 95% interval 3.08% |
| Staff COVID-19 vaccination coverage | 1.75% |
8.2%
6.4 pts worse
|
Numerator 1 · Denominator 57 |
| Staff flu vaccination coverage | 9.09% |
42%
32.9 pts worse
|
Numerator 12 · Denominator 132 |
| Discharge function score | 34.21% |
56.45%
22.2 pts worse
|
Numerator 13 · Denominator 38 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 20 · Denominator 20 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 28 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | 18.75% |
25.2%
6.4 pts worse
|
Numerator 6 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
1.9
1 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.4 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.9 |
2.2
1.7 pts worse
|
1.8
2.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.9 · Observed 3.3 · Expected 1.4 · 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 | 100.0% |
96.2%
3.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.4% |
3.8%
4.6 pts worse
|
3.3%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 8.9% · Q3 10.0% · Q4 8.5% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
15.2%
13.3 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 18.6% |
6.7%
11.9 pts worse
|
5.4%
13.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 19.4% · Q3 15.2% · Q4 13.5% · 4Q avg 18.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 40.4% |
29.6%
10.8 pts worse
|
19.6%
20.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.6% · Q2 38.5% · Q3 35.3% · Q4 43.6% · 4Q avg 40.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.3% |
17.6%
4.7 pts worse
|
16.7%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 17.9% · Q3 22.2% · Q4 23.5% · 4Q avg 22.3% · 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 | 19.3% |
17.3%
2 pts worse
|
16.3%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 22.2% · Q3 29.0% · Q4 6.7% · 4Q avg 19.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.8% |
15.6%
2.2 pts worse
|
14.9%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 29.4% · Q3 20.0% · Q4 8.1% · 4Q avg 17.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.1% |
0.7%
1.4 pts worse
|
1.0%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 6.3% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.7%
About the same
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.8% · Q3 2.6% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.7% |
19.8%
9.9 pts worse
|
19.8%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 43.3% · Q3 28.7% · Q4 26.1% · 4Q avg 29.7% |
| Percentage of long-stay residents with pressure ulcers | 7.6% |
5.5%
2.1 pts worse
|
5.1%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 8.5% · Q3 4.1% · Q4 4.0% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
83.8%
14.5 pts better
|
81.7%
16.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.3% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.0% |
13.9%
7.1 pts worse
|
12.0%
9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.0% · Observed 18.9% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 6.0% |
1.8%
4.2 pts worse
|
1.6%
4.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 11.5% · Q3 7.1% · Q4 0.0% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.7% |
83.6%
14.1 pts better
|
79.7%
18 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.5% |
24.5%
4 pts better
|
23.9%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.5% · Observed 18.9% · Expected 21.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-04-21 · Fire 2022-04-21
5 health deficiencies
Top issue: Infection Control (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-02-21 · Fire 2019-02-21
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-15
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-09-04
E · Potential for more than minimal harm
2025-08-15
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 2025-09-17
E · Potential for more than minimal harm
2025-08-15
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-09-10
D · Potential for more than minimal harm
2025-08-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-04
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-09-11
D · Potential for more than minimal harm
2025-08-15
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-09-11
D · Potential for more than minimal harm
2025-08-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-09-11
D · Potential for more than minimal harm
2025-08-15
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 2025-09-11
D · Potential for more than minimal harm
2022-04-21
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-05-11
D · Potential for more than minimal harm
2022-04-21
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 2021-04-16
D · Potential for more than minimal harm
2022-04-21
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 2022-05-09
D · Potential for more than minimal harm
2022-04-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-11
D · Potential for more than minimal harm
2022-04-21
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-05-11
F · Potential for more than minimal harm
2019-02-21
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2019-03-08
D · Potential for more than minimal harm
2019-02-21
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 2019-03-22
D · Potential for more than minimal harm
2019-02-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-03-22
Penalties and ownership
What sits behind the stars
$4,893
2024-01-08
Fine
Fine · fine $4,893
Fine
$4,545
2024-01-02
Fine
Fine · fine $4,545
Fine
$13,762
2023-12-11
Fine
Fine · fine $13,762
Fine
$4,235
2023-11-20
Fine
Fine · fine $4,235
Fine
$3,882
2023-11-13
Fine
Fine · fine $3,882
Fine
$3,529
2023-11-06
Fine
Fine · fine $3,529
Fine
$3,147
2023-10-30
Fine
Fine · fine $3,147
Fine
$7,342
2023-10-10
Fine
Fine · fine $7,342
Fine
Ownership
Nearby options
Other facilities in reach
#1
Springfield Nursing and Rehabilitation Center
Springfield, KY
4-star overall rating with 4-star inspections
#2
Loretto Living Center At Loretto Motherhouse, Inc
Nerinx, KY
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
#3
Sansbury Care Center
Saint Catharine, KY
5-star overall rating with 4-star inspections with $5,346 in total fines with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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