Willowbrook Healthcare — nursing home in Carlisle, KY

Facility type: Nursing home · SNF / NF
CMS provider type: Medicare and Medicaid
Certified beds: 71 CMS-certified beds (not state-licensed beds)
Licensed beds: 104 state-licensed beds · Kentucky Cabinet for Health and Family Services
State license: 100349 active · licensee WILLOWBROOK HEALTHCARE GROUP, LLC
Average residents per day: 47.4 CMS, MDS-derived
CMS Certification Number: 185489
Certification status: Active CMS certification Verified
First approved (Medicare/Medicaid): May 14, 2025
Ownership type: For profit - Corporation
Operator (legal business name): Willowbrook Healthcare Group LLC
CMS chain: Not part of a CMS-reported chain
Phone: (859) 651-2400
Resident & family council: Resident
Sprinklers in all required areas: Yes
Official profile: Medicare Care Compare ↗

Inspection record · CMS window

Verified

Inspections

4

latest May 28, 2026

Citations

18

8 health · 10 fire

Harm or worse

0

no immediate jeopardy

Severity	Isolated	Pattern	Widespread
Immediate jeopardy	J·	K·	L·
Actual harm	G·	H·	I·
Potential harm	D8	E5	F5
Minimal	A·	B·	C·

CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.

CMS Five-Star ratings

Federal · CMS

Overall

Health inspections

Staffing

Quality measures

Penalties · about the last 3 years

Fines

0

$0

Payment denials

0

Latest

—

Federal certification

Federal · CMS

Authority: Centers for Medicare & Medicaid Services (CMS), surveyed by the state survey agency
CCN: 185489
Program: Medicare and Medicaid
Medicare (SNF): Certified
Medicaid (NF): Certified
Certified beds: 71
First approved: May 14, 2025
Located in a hospital: No
Status: Active CMS certification as of CMS release Oct 30, 2026
Evidence: Verified

State license

Authority: Kentucky Cabinet for Health and Family Services, Office of Inspector General
License number: 100349
State facility ID: 100349
License type: Long-term care license (104 nursing facility beds)
License status: active
Licensed beds: 104
Link to CMS record: Linked by exact street address + ZIP Inferred
Licensee: WILLOWBROOK HEALTHCARE GROUP, LLC
Current license: Jun 1, 2026 → May 31, 2027
As of: Oct 30, 2026
Evidence: Inferred source ↗

Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.

CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.

Date	Domain	Survey types	Citations	Most severe	Open
May 28, 2026	Fire safety	Fire Safety Standard	10	Potential harm	—	Open →
May 28, 2026	Health	Health Standard	8	Potential harm	—	Open →
May 14, 2025	Fire safety	Fire Safety Standard	0	No citations	—	Open →
May 14, 2025	Health	Health Standard	0	No citations	—	Open →

Enforcement

Penalties

Civil money penalties and denials of payment for new admissions, as published by CMS (about the last three years). Amounts may change on appeal.

No fines or payment denials in the CMS Penalties file for this CCN.

Scope × severity

Severity	Isolated	Pattern	Widespread
Immediate jeopardy	J·	K·	L·
Actual harm	G·	H·	I·
Potential harm	D8	E5	F5
Minimal	A·	B·	C·

By concept

Date	Tag	Deficiency	Scope / severity	Correction
May 28, 2026	E-0004	Develop and maintain an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies · Emergency preparedness	F · Potential harm Widespread	Corrected Jun 22, 2026
May 28, 2026	K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Jun 22, 2026
May 28, 2026	K-0324	Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Jun 22, 2026
May 28, 2026	K-0353	Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Jun 22, 2026
May 28, 2026	K-0355	Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Jun 22, 2026
May 28, 2026	K-0712	Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety	E · Potential harm Pattern	Corrected Jun 22, 2026
May 28, 2026	K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Jun 22, 2026
May 28, 2026	K-0918	Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Jun 22, 2026
May 28, 2026	K-0920	Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety	D · Potential harm Isolated	Corrected Jun 22, 2026
May 28, 2026	K-0921	Ensure that testing and maintenance of electrical equipment is performed. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety	F · Potential harm Widespread	Corrected Jun 22, 2026
May 28, 2026	F-0604	Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect	E · Potential harm Pattern	Corrected Jun 30, 2026
May 28, 2026	F-0628	Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights Deficiencies · Resident rights & abuse/neglect	D · Potential harm Isolated	Corrected Jun 30, 2026
May 28, 2026	F-0641	Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Jun 30, 2026
May 28, 2026	F-0656	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Jun 30, 2026
May 28, 2026	F-0695	Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care	D · Potential harm Isolated	Corrected Jun 30, 2026
May 28, 2026	F-0761	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. Pharmacy Service Deficiencies · Medication management	E · Potential harm Pattern	Corrected Jun 30, 2026
May 28, 2026	F-0812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration	D · Potential harm Isolated	Corrected Jun 30, 2026
May 28, 2026	F-0880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention	D · Potential harm Isolated	Corrected Jun 30, 2026

“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.

Five-Star ratings

Federal · CMS

Overallstate 3

Health inspectionsstate 2.9

Staffingstate 2.8

Quality measuresstate 3.3

Long-stay QM

Short-stay QMNot rated

CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.

Nurse staffing · hours per resident per day

Total nurse staffing5.24

State avg 3.99US avg 3.90

Registered nurse (RN)0.63

State avg 0.80US avg 0.69

Licensed practical nurse0.90

State avg 0.80US avg 0.86

Nurse aide3.71

State avg 2.39US avg 2.35

Weekend total nurse4.81

State avg 3.48US avg 3.43

Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 4.87 (case-mix index 1.51).

Staff turnover

Total nursing staff turnoverNot reported

State avg 45.4%US avg 45.3%

Registered nurse turnoverNot reported

State avg 40.8%US avg 42.5%

Administrators who leftNot reported

State avg 0US avg 1

Health survey score

Cycle 1 standard survey: May 28, 2026
Cycle 1 health score: 40
Total weighted score: 30

Operating entity

Willowbrook Healthcare Group LLC

CMS legal business name of the certified provider. Operates this facility only.

VerifiedLinked by exact legal name

CMS chain

Not part of a CMS-reported chain.

Ownership disclosures

Disclosures

24

Organizations

5

Individuals

18

Direct & indirect ownership

Owners of record

Name	Type	Role (Carefield group)	CMS role text	Share	Since
Jay Frances	Individual	Direct owner	5% OR GREATER DIRECT OWNERSHIP INTEREST	50%	Feb 1, 2025
Mollyanne Frances	Individual	Direct owner	5% OR GREATER DIRECT OWNERSHIP INTEREST	50%	Feb 1, 2025

CMS Ownership file

All disclosed roles

Operator, owners, managers, officers and lenders are distinct roles and are never flattened into one entity. Organizations link across facilities by exact normalized legal name; individuals are listed per facility only.

Name	Type	Role (Carefield group)	CMS role text	Share	Since
Jay Frances	Individual	Direct owner	5% OR GREATER DIRECT OWNERSHIP INTEREST	50%	Feb 1, 2025
Mollyanne Frances	Individual	Direct owner	5% OR GREATER DIRECT OWNERSHIP INTEREST	50%	Feb 1, 2025
Kimberly Smith	Individual	Partner	INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF	not provided	Apr 1, 2025
Jay Frances	Individual	Operational / managerial control	MANAGING CONTROL - GOVERNING BODY	not provided	Feb 1, 2025
Mollyanne Frances	Individual	Operational / managerial control	MANAGING CONTROL - GOVERNING BODY	not provided	Feb 1, 2025
Legacy Health Services Inc	Organization	Operational / managerial control	OPERATIONAL/MANAGERIAL CONTROL	not provided	Feb 1, 2025
Roy Baber	Individual	Operational / managerial control	OPERATIONAL/MANAGERIAL CONTROL	not provided	Feb 1, 2025
Calhoun & Company PLLC	Organization	Additional disclosable party	ADP OF THE SNF	not provided	Feb 1, 2025
Hargis & Associates, LLC	Organization	Additional disclosable party	ADP OF THE SNF	not provided	Feb 1, 2025
Legacy Health Services Inc	Organization	Additional disclosable party	ADP OF THE SNF	not provided	Feb 1, 2025
Nicholas County Fiscal Court	Organization	Additional disclosable party	ADP OF THE SNF	not provided	Feb 1, 2025
Proactive Medical Review and Consultants LLC	Organization	Additional disclosable party	ADP OF THE SNF	not provided	Feb 1, 2025
Veronica Anderson	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Feb 1, 2025
Roy Baber	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Feb 1, 2025
Barry Chatham	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Feb 1, 2025
Brian Chatham	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Feb 1, 2025
Stephen Chatham	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Feb 1, 2025
Debbie Fuller	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Feb 1, 2025
Forwood Hargis	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Feb 1, 2025
Karen Kreil	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Feb 1, 2025
Arnie Martin	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Feb 1, 2025
Sarah Mcintosh	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Feb 1, 2025
Jalme Petersen	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Feb 1, 2025
Stephen Toadvine	Individual	Additional disclosable party	ADP OF THE SNF	not provided	Feb 1, 2025

No building or property record is linked to this facility yet. Parcel, assessor and building-permit joins will be added only where a valid site match exists.

Coordinates as published by CMS.

Address: 2323 Concrete Road, Carlisle, KY 40311
ZIP: 40311
County: Nicholas County FIPS 21181
State: Kentucky
Urban / rural (CMS): Rural

Within ~25 km

Nearby nursing homes

No nearby facilities with coordinates.

Source	Record	Facts	Evidence	Source release	Retrieved
CMS Provider Information US-CMS	185489	name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain	Verified	Oct 1, 2026	Nov 7, 2026
CMS Provider Information US-CMS	185489	ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only.	Verified	Oct 1, 2026	Nov 7, 2026
Kentucky OIG Long Term Care Directory KY	100349	state_license, licensed_beds, licensee Linked to the CMS record by exact normalized street address and ZIP (the state roster does not publish the CCN).	Inferred	Oct 30, 2026	Nov 7, 2026

Record-level source links for CCN 185489

First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction