Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Letcher Manor
Whitesburg, KY · 142 certified beds · Last Life Safety survey February 27, 2025
CMS Certification Number 185200 · first certified October 1989
Ownership
Operated by BLUEGRASS HEALTH KY · For profit - Corporation
- Ownership changed November 1, 2016 (change of ownership)from DJ LETCHER MANOR LLC
Position within KY
11 citations — more than 66% of the 267 certified nursing homes in KY. Compared within KY rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 2 citations; the earlier surveys in the window averaged 4.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: April 2026 to January 2030. This facility’s last Life Safety survey was February 2025. Facilities in KY are typically surveyed 14–59 months after the last one (median 28), measured over 391 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 11 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in KY, and nationally. Surveyors differ markedly between states, so the KY figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 11 |
| Median facility in KY | 7 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 7, 2019 | 0 |
| April 5, 2024 | 9 |
| February 27, 2025 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2024-04-05 |
| K-0781 | Have restrictions on the use of portable space heaters. | 1 | 2025-02-27 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2025-02-27 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 1 | 2024-04-05 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2024-04-05 |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | 1 | 2024-04-05 |
| K-0923 | Have proper medical gas storage and administration areas. | 1 | 2024-04-05 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2024-04-05 |
What the citations cover
- Smoke Deficiencies 7
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Miscellaneous Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 7 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
February 27, 2025 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 19, 2025) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (March 19, 2025) |
April 5, 2024 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (May 2, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (May 2, 2024) |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | Deficient, Provider has date of correction (May 2, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (May 2, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (May 2, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (May 2, 2024) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (May 2, 2024) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (May 2, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (May 2, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.