Willowbrook Healthcare
2323 Concrete Road, Carlisle, KY 40311 · Nicholas County · (859) 651-2400
71 certified beds, about 41 residents a day · For profit - Corporation · Medicare and Medicaid since 2025
Certified for Medicaid Certified for Medicare
Overall
2 of 5
Health inspections
2 of 5
Staffing
4 of 5
Quality measures
4 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 185489 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on May 28, 2026, inspectors cited 8 health deficiencies (the Kentucky average is 2.9, the national average 9.2).
None of its 8 health citations since May 2025 was rated as actual harm or immediate jeopardy.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 5.93 hours per resident per day, against 3.95 across Kentucky and 3.86 nationally. Registered nurses accounted for 0.68 of those hours.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
005/25
805/26
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 8 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
6D
2E
0F
Potential for minimal harm
0A
0B
0C
May 28, 2026Standard inspection · 8 citations
- E Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to ensure residents were free from physical restraints, failed to have documented evidence of assessments for the restraints, and failed to document ongoing re-evaluation of the need for the restraints when the use of restraints was indicated, for 3 of 3 sampled residents, Resident (R) 10, R38, and R41. Observations of R10, R38, and R41 on 05/26/2026 and 05/27/2026 revealed the residents sitting in their motorized wheelchairs with a restraint device on the residents.
- E 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.
Inspectors wroteBased on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, review of the American Diabetic Association's (ADA) document, review of manufacturer's guidelines, and review of the facility's policy, the facility failed to ensure all medications were stored in a manner that protected them from temperature changes, humidity changes, and exposure to light for 1 of 2 medication rooms, the North Hall medication room.
- D Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to notify the resident and the resident's representative(s) of the transfer to the emergency department and the reasons for the move in writing and in a language and manner they understood and provide written information to the resident or resident representative of the duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility for 2 of 3 sampled residents, Resident (R) 6 and R7. On 4/30/2026, R7 was sent to the local emergency room due to her having an unwitnessed fall in the bathroom. R7 did not receive a bed hold/transfer notice prior to being sent out from the facility. During an interview with the Family Representative of R7, she stated she did not receive any documents by mail for a bed hold/transfer notice. [...]
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview, record review, and review of the facility's job description, the facility failed to ensure Minimum Data Set [MDS] assessments accurately reflected the residents' status for 3 of 17 sampled residents, Resident (R) 10, R38, and R41 for physical restraints.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview, record review, review of a facility job description, and review of the facility's policy, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 35 sampled residents, Resident (R) 41. R41 was observed wearing a gait belt wrapped around his legs that was not ordered or addressed on the comprehensive care plan.
- D Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, record review and review of the facility's policy, the facility failed to ensure residents receiving respiratory care was provided services in accordance with physician orders and the facility's protocol for 2 of 16 sampled residents, Resident (R) 52 and R8. Record review revealed R52 had an order for oxygen administration at two liters per minute (LPM) via nasal cannula. However, observations conducted on 05/27/2026 and 05/28/2026 revealed R52 was receiving oxygen via nasal cannula with the regulator set at two and one-half and three LPM, which was not consistent with the physician's order. Observation on 05/26/2026 at 1:29 PM revealed R8's oxygen tubing and the distilled water were not dated.
- D Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, for 1 of 5 staff members observed in the kitchen, Dietary Aide (DA) 2.
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review, and review of facility policies, the facility failed to follow infection prevention and control policies to help prevent the development and transmission of communicable diseases and infection for 3 of 17 sampled residents (R3, R16, and R47).
May 14, 2025Standard inspection · 0 citations
Fire safety inspections
10 fire safety citations on file: 10 on May 28, 2026.
Every fire safety citation10 citations
- F Develop and maintain an Emergency Preparedness Program (EP).
- F Inspect, test, and maintain automatic sprinkler systems.
- F To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- F Have generator or other power source capable of supplying service within 10 seconds.
- F Ensure that testing and maintenance of electrical equipment is performed.
- E Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E Provide properly protected cooking facilities.
- E Have simulated fire drills held at unexpected times.
- D Properly select, install, inspect, or maintain portable fire extinguishes.
- D Ensure proper usage of power strips and extension cords.
Fines and payment denials
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Kentucky | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 5.93 | 3.95 | 3.86 |
| Registered nurses | 0.68 | 0.79 | 0.69 |
| All nursing staff on weekends | 5.43 | 3.49 | 3.42 |
| Nurse aides | 4.36 | ||
| Licensed practical nurses | 0.89 | ||
| Nursing staff turnover (share who left in a year) | not reported | 46.4% | 45.8% |
| Registered nurse turnover | not reported | 41.8% | 42.9% |
| Administrators who left | not reported |
CMS expects 4.23 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 6.13 on weekdays and 5.43 on weekends, 11% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 9.28 in July to September 2025 to 5.93 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 5.93 | 0.68 | 6.13 | 5.43 | 0.0% | 1 of 90 | 41 |
| Oct to Dec 2025 | 5.39 | 0.66 | 5.57 | 4.92 | 0.1% | 0 of 92 | 34 |
| Jul to Sep 2025 | 9.28 | 1.84 | 9.82 | 7.93 | 0.1% | 0 of 92 | 9 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Kentucky, Jan to Mar 2026 | 3.85 | 0.71 | 4.04 | 3.40 | 3.2% | 0.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Kentucky | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 16.7 | 13.8 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.0 | 0.5 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 9.1 | 1.6 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 7.3 | 3.9 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 9.5 | 1.7 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 20.2 | 14.0 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 2.7 | 4.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 15.9 | 16.1 | 15.4 |
Owners and operators
Legal business name: WILLOWBROOK HEALTHCARE GROUP LLC.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Frances, Jay | 5% or greater direct ownership interest | Individual | 50% | 02/01/2025 |
| Frances, Mollyanne | 5% or greater direct ownership interest | Individual | 50% | 02/01/2025 |
| Frances, Jay | Managing control - governing body | Individual | 02/01/2025 | |
| Frances, Mollyanne | Managing control - governing body | Individual | 02/01/2025 | |
| Legacy Health Services Inc | Operational/managerial control | Organization | 02/01/2025 | |
| Baber, Roy | Operational/managerial control | Individual | 02/01/2025 | |
| Smith, Kimberly | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 04/01/2025 | |
| Calhoun & Company PLLC | Adp of the SNF | Organization | 02/01/2025 | |
| Hargis & Associates, LLC | Adp of the SNF | Organization | 02/01/2025 | |
| Legacy Health Services Inc | Adp of the SNF | Organization | 02/01/2025 | |
| Nicholas County Fiscal Court | Adp of the SNF | Organization | 02/01/2025 | |
| Proactive Medical Review and Consultants LLC | Adp of the SNF | Organization | 02/01/2025 | |
| Anderson, Veronica | Adp of the SNF | Individual | 02/01/2025 | |
| Baber, Roy | Adp of the SNF | Individual | 02/01/2025 | |
| Chatham, Barry | Adp of the SNF | Individual | 02/01/2025 | |
| Chatham, Brian | Adp of the SNF | Individual | 02/01/2025 | |
| Chatham, Stephen | Adp of the SNF | Individual | 02/01/2025 | |
| Fuller, Debbie | Adp of the SNF | Individual | 02/01/2025 | |
| Hargis, Forwood | Adp of the SNF | Individual | 02/01/2025 | |
| Kreil, Karen | Adp of the SNF | Individual | 02/01/2025 | |
| Martin, Arnie | Adp of the SNF | Individual | 02/01/2025 | |
| McIntosh, Sarah | Adp of the SNF | Individual | 02/01/2025 | |
| Petersen, Jalme | Adp of the SNF | Individual | 02/01/2025 | |
| Toadvine, Stephen | Adp of the SNF | Individual | 02/01/2025 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- When is the care plan meeting, and can family attend it?Inspectors cited 2 problems in this area, most recently on May 28, 2026: "Ensure each resident receives an accurate assessment."
- How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 1 problem in this area, most recently on May 28, 2026: "Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 1 problem in this area, most recently on May 28, 2026: "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."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 1 problem in this area, most recently on May 28, 2026: "Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies."
Other nursing homes nearby
- Harrison Nursing and Rehabilitation Center Cynthiana, 14.1 mi · 1 of 5 stars · 39 citations
- Edgemont Healthcare Cynthiana, 14.3 mi · 1 of 5 stars · 26 citations
- Bourbon Heights Nursing Home Paris, 14.5 mi · 1 of 5 stars · 29 citations
- Robertson County Health Care Facility Mount Olivet, 15.3 mi · 4 of 5 stars · 6 citations
- Cedar Ridge Health Campus Cynthiana, 15.7 mi · 5 of 5 stars · 5 citations
- Pioneer Trace Group LLC Flemingsburg, 17.4 mi · 1 of 5 stars · 12 citations
- Mt. Sterling Health & Rehab, LLC Mount Sterling, 19.1 mi · 1 of 5 stars · 26 citations
- Ridgeway Nursing & Rehabilitation Facility Owingsville, 19.6 mi · 3 of 5 stars · 20 citations
Kentucky contacts for a concern about a nursing home
These are the official offices in Kentucky. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Kentucky Office of Inspector General, Division of Health Care, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Kentucky State Long-Term Care Ombudsman Program, Nursing Home Ombudsman Agency of the Bluegrass, (800) 372-2991. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Kentucky OIG Nursing Home Inspection Findings, where Kentucky publishes its own records on licensed homes.
Common questions
- What is Willowbrook Healthcare's Medicare star rating?
- CMS rates Willowbrook Healthcare 2 out of 5 stars overall, with 2 for health inspections, 4 for staffing and 4 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Willowbrook Healthcare get at its last inspection?
- 8 health deficiencies at the standard inspection on May 28, 2026. The Kentucky average is 2.9.
- Has Willowbrook Healthcare been fined?
- CMS lists no fines in the last three years.
- Does Willowbrook Healthcare accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Willowbrook Healthcare?
- CMS lists 24 owners and managers. Legal business name: WILLOWBROOK HEALTHCARE GROUP LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.