Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brighton Cornerstone Group, Llc during CMS and state inspections, most recent first.
Failure to Inform Residents About Psychotropic Medication Use: The facility did not document that residents or their representatives were informed of the risks and benefits of psychotropic medications before use for five residents receiving antipsychotic, antidepressant, and antianxiety drugs. Records showed residents with diagnoses such as dementia, depression, and anxiety were receiving medications including risperidone, mirtazapine, quetiapine, citalopram, buspirone, and escitalopram, but there was no evidence of informed consent or discussion of alternatives. The DON stated the facility only obtained a general consent to treat and did not know that risks and benefits needed to be discussed before psychotropic use.
Medication administration errors exceeded the allowed rate when a CMT made multiple errors during observed med passes for two residents. Errors included giving incomplete doses of polyethylene glycol, failing to have residents rinse and spit after inhaler use, applying ophthalmic gel to both eyes instead of one eye as ordered, and administering less lactulose than prescribed. The facility policy required meds to be given according to orders and the five rights checked three times.
Failure to Provide Medicare Non-Coverage Notices: The facility did not provide a NOMNC or SNF ABN to a resident before Medicare Part A coverage ended. The resident had dementia with severe cognitive impairment, and records showed the resident was discharged from covered skilled services while benefit days remained. The DON and Corporate [NAME] Specialist stated the required notices were not issued because an email was missed and the paperwork was not completed due to oversight.
Failure to Offer Shaving During ADL Care: A resident with intact cognition and multiple chronic conditions, including COPD, DM, and chronic pain, was found with long facial hair despite receiving showers. Staff documented bathing but not shaving, and the resident stated they disliked the facial hair and had not been shaved. A CNA said she did not shave the resident because they did not ask, while an LPN and the DON stated shaving should be offered during shower care when needed.
Failure to implement EBP for a resident with a feeding tube. An LPN entered the room wearing only gloves and administered medication via the feeding tube without a gown; there was no EBP signage or PPE supplies at the door. The resident had severe cognitive impairment and required tube feeding. The facility policy stated EBP applies to residents with indwelling devices such as feeding tubes, but the LPN and DON stated the facility had only been using EBP for MDRO cases.
The facility failed to follow professional standards for food service safety, affecting all 36 residents. Observations showed improper food storage, including uncovered and outdated items not rotated properly. Staff interviews confirmed non-compliance with policies, posing a risk of foodborne illnesses.
The facility failed to provide RN coverage for 8 consecutive hours daily, as required, on 15 occasions. Discrepancies in the PBJ Staffing Data Report were identified, with the DON claiming to have worked the required hours, but the report not reflecting this. Interviews revealed issues with data entry and reporting processes, particularly for salaried staff, leading to inaccurate documentation of RN coverage.
The facility failed to properly store and label a vial of Tubersol solution, which was found in the medication refrigerator past its expiration date. An LPN confirmed that the night shift staff was responsible for discarding expired items, but the expired Tubersol was overlooked. The DON and Administrator acknowledged the oversight and emphasized the importance of checking expiration dates to prevent inaccurate test results.
An LPN failed to follow proper infection control procedures during wound care for two residents. For one resident, the LPN did not clean the bedside table or use a barrier before placing wound supplies. For another resident, the LPN did not use a protective barrier under the foot, failed to clean the wound bed, and continued with torn gloves. The DON and Administrator expected adherence to infection control policies.
Failure to Inform Residents and Representatives About Psychotropic Medication Risks and Benefits
Penalty
Summary
The facility failed to ensure residents were fully informed and able to participate in their treatment by not informing residents and/or their representatives in advance of the risks and benefits of psychotropic medication use before those medications were administered. The deficiency involved 5 of 5 residents reviewed for unnecessary medications: Residents 2, 20, 6, 4, and 5. The report states there was no evidence in any of these residents’ records that they or their representatives were educated about the risks or benefits of the psychotropic medications, and no evidence of consent for use of those medications. Resident 2 had diagnoses including anxiety disorder, vascular dementia with psychotic disturbance, and major depressive disorder, had a BIMS score of 15, and was receiving risperidone for dementia with psychosis. Resident 20 had major depressive disorder, had a BIMS score of 15, and was receiving mirtazapine for appetite/depression. Resident 6 had major depressive disorder and anxiety disorder, had a BIMS score of 4, and was receiving mirtazapine for depression/appetite. The records for these residents showed the medications were being administered according to orders, but there was no evidence of informed discussion or consent regarding the psychotropic medications. Resident 4 had diagnoses including vascular dementia with behavioral disturbance and agitation, anxiety disorder, and major depressive disorder, had severe impairment in cognitive skills for daily decision-making, and was receiving citalopram, buspirone, and quetiapine. Resident 5 had a diagnosis of depression, had a BIMS score of 15, and was receiving escitalopram for depression. The facility policy titled Antipsychotic Medication Use addressed use of antipsychotics after causes of behavioral symptoms were identified and addressed, but it did not address discussing risks and benefits with residents or representatives before administration. During interviews, the Administrator/Interim DON stated the facility did not obtain consents for psychotropic medication use, only general consent to treat, and stated she was not aware that risks and benefits needed to be discussed before use.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5 percent. Surveyors identified six errors out of 26 medication administration opportunities, resulting in a 23.08% error rate and affecting two residents observed during medication pass. The facility policy required medications to be administered safely and in accordance with orders, including checking the label three times to verify the right resident, medication, dosage, time, and route before administration. One resident admitted with COPD, type 2 diabetes, hypertension, and irritable bowel syndrome had active orders for polyethylene glycol powder and Symbicort inhaler. During observation, a CMT mixed the polyethylene glycol powder with 4 to 5 ounces of water but did not ensure the resident consumed the full amount, discarding about 2 ounces. The CMT also administered two puffs of Symbicort but did not have the resident rinse and spit afterward as ordered and as directed by the manufacturer instructions. A second resident admitted with type 2 diabetes with neuropathy, COPD, Alzheimer's disease, hepatic encephalopathy, and cicatricial lagophthalmos had active orders for Breo Ellipta inhaler, polyethylene glycol-propylene glycol ophthalmic gel to the left eye, polyethylene glycol powder, and lactulose. During observation, the CMT mixed polyethylene glycol powder with approximately 4 ounces of water but administered only about 2 ounces, gave the inhaler without requiring rinse and spit, applied eye gel to both eyes instead of only the left eye, and administered 30 milliliters of lactulose instead of the ordered 45 milliliters. In interview, the CMT acknowledged not having residents rinse and spit after inhaler use, applying the eye gel to both eyes, and giving less lactulose than ordered.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to ensure that one of two sampled residents reviewed for beneficiary notifications, Resident 14, was provided a Notice of Medicare Non-Coverage (NOMNC) and a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) before the end of covered Medicare Part A services. Facility policy stated that the NOMNC must be delivered at least two calendar days before Medicare-covered services end, or the second to last day of service if care is not provided daily. Resident 14 was admitted on 07/22/2025 and had diagnoses including dementia, depression, and diabetes mellitus. A quarterly MDS with an ARD of 10/21/2025 showed a BIMS score of 4, indicating severe cognitive impairment. Records showed the resident was discharged from a Medicare-covered Part A stay on 12/05/2025 but remained in the facility, and the facility's SNF Beneficiary Notice Scenarios for Surveyors form showed the facility initiated the discharge from Medicare Part A services while benefit days were not exhausted. During interviews, the Administrator/Interim DON stated she missed an email notifying her that the resident's payor source was changing and therefore did not issue the NOMNC or SNF ABN. The Corporate [NAME] Specialist stated she was notified in a timely manner but did not issue the required notices due to an oversight.
Failure to Offer Shaving During ADL Care
Penalty
Summary
The facility failed to provide necessary ADL care for Resident 12 by not offering shaving during shower care. Resident 12 was admitted on 03/03/2025 and readmitted on 06/03/2025 with diagnoses including left humerus fracture, COPD, asthma, diabetes mellitus, peripheral vascular disease, hypertension, GERD, chronic pain, major depressive disorder, morbid obesity, anxiety disorder, dysphagia, and diverticulosis. The quarterly MDS dated 12/01/2025 showed a BIMS score of 13, indicating intact cognition, and the resident required set-up or clean-up assistance for eating and supervision or touching assistance for bathing. The care plan identified a self-care deficit related to general weakness and directed staff to assist with bathing daily per schedule and resident preference, shampoo hair with showers, keep nails clean, and provide privacy and explanation before care. December 2025 and January 2026 bath/shower documentation showed the resident received showers at least twice weekly, but there was no documentation that shaving was offered or completed. On 01/05/2026, the resident was observed with long facial hair on the chin and stated they disliked the length of the facial hair and had not been shaved after the morning shower. The resident continued to be observed on 01/06/2026 and 01/07/2026 with long facial hair on the chin and increased hair growth on the upper lip. CNA #6 stated she gave the resident a shower on Monday but did not shave them because the resident did not ask and she did not think about it, and she should have offered. CNA #5 and LPN #3 stated residents should be shaved on shower days if needed and should not have to ask. The DON stated shaving should be offered and completed during showers when facial hair is visible and said the resident should have been shaved with the shower on Monday.
Failure to Implement Enhanced Barrier Precautions for Feeding Tube Care
Penalty
Summary
The facility failed to ensure staff implemented Enhanced Barrier Precautions (EBP) and followed infection prevention and control practices for Resident 29, who was admitted with diagnoses including traumatic subarachnoid hemorrhage with loss of consciousness, non-traumatic subarachnoid hemorrhage from the anterior communicating artery, hypertension, vitamin B deficiency, anemia, anxiety disorder, seizures, and muscle spasms. The admission MDS showed the resident had severe impairment in cognitive skills for daily decision-making and required a feeding tube, receiving 51% or more of total calories and 501 cc or more of fluid via tube feeding each day. The care plan identified a potential for nutritional problems related to NPO status and directed staff to administer medications and tube feeding as ordered. During observation, an LPN entered the resident's room without the proper PPE, wearing only gloves, and administered medication through the feeding tube. There was no signage on the door indicating the resident was on EBP, and there were no PPE supplies in the room or in the hallway outside the door. The facility policy stated EBP should be used for residents with indwelling medical devices, including feeding tubes, even if they were not known to be infected or colonized with an MDRO. In interview, the LPN stated she did not know she was supposed to wear a gown for feeding tube care and believed EBP was only required for MDROs or at physician discretion. The Administrator/Interim DON stated the facility only implemented EBP for MDROs based on consultant guidance and acknowledged after reviewing the policy that EBP should have been implemented for residents with wounds, catheters, and feeding tubes.
Improper Food Storage and Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, which had the potential to affect all 36 residents who consumed food from the kitchen. Observations revealed multiple instances of improper food storage, including uncovered and exposed food items in refrigerators and freezers, as well as outdated items that were not rotated according to the first in-first out (FIFO) system. Specifically, an opened box of cream cheese, bags of broccoli, salad lettuce, ground beef patties, sausage patties, and oatmeal raisin cookie dough were found uncovered and exposed to air. Additionally, dry pantry storage bins containing cornmeal and flour were undated, failing to comply with the facility's policy for labeling and dating food items. Interviews with staff, including the Dietary Manager and the Administrator, confirmed that the facility's policies and procedures for food safety were not being followed. Staff acknowledged the importance of covering, dating, and rotating food items to prevent contamination and ensure food safety. The Dietary Manager emphasized the need for in-service training if staff failed to adhere to these guidelines. The Administrator expressed expectations for staff to follow safe food practices, including knowledge of expiration dates and proper rotation of food items. The failure to comply with these standards posed a risk of exposing residents to foodborne illnesses such as E.coli and salmonella.
Inadequate RN Coverage and Reporting Discrepancies
Penalty
Summary
The facility failed to ensure the services of a Registered Nurse (RN) were utilized for at least 8 consecutive hours a day, 7 days a week, as required by federal regulations. This deficiency was identified through a review of the facility's staffing schedules and Payroll-Based Journal (PBJ) Staffing Data Report, which revealed a lack of RN coverage for 15 specific dates between July 27, 2024, and September 29, 2024. The Director of Nursing (DON) claimed to have worked the required hours on weekends, but the PBJ Report did not reflect this, indicating a discrepancy in the documentation of RN coverage. Interviews with the DON, Corporate Account Specialist (CAS), and Administrator revealed issues with the PBJ reporting process. The CAS, responsible for submitting the PBJ data, admitted to potential errors in data entry, particularly for salaried employees like the DON and Administrator, whose hours were manually entered. The Administrator acknowledged the lack of training in PBJ reporting and relied on daily census sheets to track staffing. These procedural gaps and lack of safeguards in data entry contributed to the inaccurate reporting of RN coverage, affecting all residents in the facility during the identified dates.
Improper Storage and Labeling of Tubersol Solution
Penalty
Summary
The facility failed to ensure that all drugs were labeled and stored in accordance with professional standards, as evidenced by the improper storage of a vial of Tubersol solution in the medication refrigerator. During an observation, it was found that the vial, which was opened on January 30, 2025, was still available for use on March 5, 2025, despite the facility's policy that such medications should be discarded after 30 days. This oversight was confirmed during an interview with an LPN, who acknowledged that the night shift nursing staff was responsible for checking and discarding expired items. Further interviews with the Director of Nursing (DON) and the Administrator revealed that the facility's policy required daily checks of the medication refrigerator by nursing staff on all shifts to ensure expired medications were discarded. The DON admitted that the expired Tubersol might have been overlooked, and the Administrator emphasized that it was the nursing staff's responsibility to check expiration dates before administering medications. The use of expired Tubersol could lead to inaccurate tuberculosis test results, as noted by the DON.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to establish and maintain a proper infection prevention and control program, as evidenced by the actions of an LPN during wound care for two residents. For Resident 3, who had a wound on the coccyx, the LPN did not clean the bedside table or place a protective barrier before placing clean wound dressing supplies on it. The LPN acknowledged the oversight, citing limited space in the resident's room as a challenge. The Director of Nursing and the Administrator both expressed that their expectations were for the staff to follow proper infection control procedures, including cleaning surfaces and using barriers. For Resident 11, who had a wound on the right plantar foot, the LPN failed to place a clean pad or protective barrier under the resident's foot during wound care. Additionally, the LPN did not clean the wound bed before applying a new dressing and continued the procedure with torn gloves caused by wearing jewelry. The LPN admitted to not following proper infection control practices, such as changing gloves when they tore. The Director of Nursing and the Administrator reiterated their expectations for adherence to the facility's infection control policy to prevent the spread of infection.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Madisonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Madisonville Health And Rehabilitation, Llc | 0.3 mi | ★★★★★ | 1 | 0 |
| Park Grove Nursing And Rehabilitation Center | 0.9 mi | ★★★★★ | 0 | 0 |
| Ridgewood Terrace Health And Rehabilitation Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Joseph Eddie Ballard Western Kentucky Veterans Cen | 5.8 mi | ★★★★★ | 4 | 0 |
| Tradewater Pointe | 15.9 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.