Cycle 1
Health 2025-06-12 · Fire 2025-06-12
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Vanceburg, KY
Vanceburg Hills
2-star overall rating with 3-star inspections with $10,527 in total fines with 3 fire-safety deficiencies in the latest cycle
58 Eastham Street, Vanceburg, KY
(606) 796-3046
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
94
Certified beds
Average residents
89
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Journey Healthcare
Operator or chain grouping
Approved since
1991-01-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 2 overall / 2 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
0.46
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.02
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.12
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.11
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
2.71
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.42
CMS adjusted RN staffing hours
Adjusted total hours
2.86
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
11,164
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.81
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
3.56
Baseline 7.75% · Performance 6.77% · Measure score 3.56 · Achievement 3.56 · Improvement 3.06
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0
Baseline 2.86 hours · Performance 2.49 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.38% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 4% · Lower 95% interval 6.26% |
| Discharge to community | 57.26% |
50.57%
6.7 pts better
|
No Different than the National Rate · Eligible stays 26 · Observed rate 57.69% · Lower 95% interval 42.61% |
| Medicare spending per beneficiary | 1.48 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 21.88% |
95.27%
73.4 pts worse
|
Numerator 7 · Denominator 32 |
| Falls with major injury | 3.13% |
0.77%
2.4 pts worse
|
Numerator 1 · Denominator 32 |
| 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 | 3.13% |
2.29%
0.8 pts worse
|
Numerator 1 · Denominator 32 · Adjusted rate 2.14% |
| Healthcare-associated infections requiring hospitalization | 6.77% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 6.25% · Lower 95% interval 3.97% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 117 |
| Staff flu vaccination coverage | 30.33% |
42%
11.7 pts worse
|
Numerator 37 · Denominator 122 |
| 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 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · 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 | 2.2 |
1.9
0.3 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.0 · 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 1.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
94.3%
5.4 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.8% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.6% |
96.2%
1.4 pts better
|
95.5%
2.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.8%
1.9 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.3% · Q3 1.2% · Q4 2.5% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 15.5% |
15.2%
0.3 pts worse
|
11.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 18.8% · Q3 16.9% · Q4 24.3% · 4Q avg 15.5% |
| Percentage of long-stay residents who lose too much weight | 8.9% |
6.7%
2.2 pts worse
|
5.4%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 13.2% · Q3 5.3% · Q4 7.8% · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 39.1% |
29.6%
9.5 pts worse
|
19.6%
19.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.4% · Q2 38.9% · Q3 44.0% · Q4 35.1% · 4Q avg 39.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.5% |
17.6%
2.9 pts worse
|
16.7%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 23.4% · Q3 15.7% · Q4 22.6% · 4Q avg 20.5% · 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 | 20.2% |
17.3%
2.9 pts worse
|
16.3%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.2% · Q2 18.9% · Q3 9.6% · Q4 5.6% · 4Q avg 20.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.8% |
15.6%
0.8 pts better
|
14.9%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 15.9% · Q3 15.9% · Q4 2.9% · 4Q avg 14.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
0.7%
0.4 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 1.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
1.7%
0.9 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 1.4% · Q3 5.0% · Q4 1.2% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.2% |
19.8%
0.4 pts worse
|
19.8%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 14.0% · Q3 31.4% · Q4 23.3% · 4Q avg 20.2% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
5.5%
0.7 pts worse
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 7.7% · Q3 5.3% · Q4 6.7% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 58.2% |
83.8%
25.6 pts worse
|
81.7%
23.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 65.9% · Q2 59.6% · Q3 55.1% · Q4 53.8% · 4Q avg 58.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.5% |
13.9%
2.4 pts better
|
12.0%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.5% · Observed 11.1% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.8%
0.4 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 3.8% · Q3 0.0% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 68.1% |
83.6%
15.5 pts worse
|
79.7%
11.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 68.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.7% |
24.5%
9.2 pts worse
|
23.9%
9.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.7% · Observed 33.3% · Expected 23.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-22 · Fire 2024-08-22
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2019-07-12 · Fire 2019-07-12
5 health deficiencies
Top issue: Environmental (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-06-12
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 2025-07-14
D · Potential for more than minimal harm
2025-06-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-07-14
D · Potential for more than minimal harm
2025-06-12
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-07-14
E · Potential for more than minimal harm
2024-08-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-24
E · Potential for more than minimal harm
2024-08-22
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-09-24
E · Potential for more than minimal harm
2024-08-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-24
E · Potential for more than minimal harm
2024-08-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-24
E · Potential for more than minimal harm
2024-08-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-24
F · Potential for more than minimal harm
2019-07-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-08-28
F · Potential for more than minimal harm
2019-07-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-08-28
Inspection history
Recent health citations
G · Actual harm
2024-08-22
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-09-24
G · Actual harm
2024-08-22
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 2024-09-24
G · Actual harm
2024-08-22
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-08-22
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-08-22
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 2024-09-24
D · Potential for more than minimal harm
2024-08-22
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-08-22
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-08-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-08-22
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-08-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-24
E · Potential for more than minimal harm
2019-07-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-08-21
E · Potential for more than minimal harm
2019-07-12
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2019-08-21
D · Potential for more than minimal harm
2019-07-12
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-08-21
D · Potential for more than minimal harm
2019-07-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-08-20
D · Potential for more than minimal harm
2019-07-12
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 2019-08-20
Penalties and ownership
What sits behind the stars
$10,527
2024-08-22
Fine
Fine · fine $10,527
Fine
$0
2024-08-22
Payment Denial
Payment Denial · denial start 2024-09-21 · 3 days
3 day denial
Ownership
3 Bees Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Ajoj Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Bees Family Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Blue Ocean Trust
5% Or Greater Indirect Ownership Interest · Organization
Gph Vanceburg LLC
5% Or Greater Security Interest · Organization
Journey Cz Ky Healthcare Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Journey Cz Management LLC
Operational/Managerial Control · Organization
Journey Cz Of Ky LLC
Limited Partnership Interest · Organization
Marshall, William
Operational/Managerial Control · Individual
Mcguinness, Bernard
Operational/Managerial Control · Individual
Shasam Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Shasam Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
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#2
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4-star overall rating with 5-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
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