Cycle 1
Health 2022-08-25 · Fire 2022-08-25
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Elizabethtown, KY
Baptist Health Hardin
5-star overall rating with 4-star inspections with 1 recent health deficiencies
913 North Dixie Avenue, Elizabethtown, KY
(270) 737-1212
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
15
Certified beds
Average residents
12
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-08-22
CMS approved date
Coverage
Medicare
Participation flags
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
4.23
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.43
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
3.24
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
7.90
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
4.66
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
7.11
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
3.68
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.29
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
4.08
CMS adjusted RN staffing hours
Adjusted total hours
7.63
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,120
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.66
Composite VBP score used to determine payment impact.
Payment multiplier
1.0149
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.35
Baseline 17.28% · Performance 19.42% · Measure score 4.35 · Achievement 4.35 · Improvement 0
Healthcare-associated infections
3.55
Baseline 6.48% · Performance 6.77% · Measure score 3.55 · Achievement 3.55 · Improvement 0
Total nurse turnover
10
Baseline 37.50% · Performance 16.00% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.82% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 272 · Observed rate 9.56% · Lower 95% interval 8.14% |
| Discharge to community | 70.22% |
50.57%
19.6 pts better
|
Better than the National Rate · Eligible stays 280 · Observed rate 70% · Lower 95% interval 65.38% |
| Medicare spending per beneficiary | 0.68 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 25.29% |
95.27%
70 pts worse
|
Numerator 43 · Denominator 170 |
| Falls with major injury | 1.18% |
0.77%
0.4 pts worse
|
Numerator 2 · Denominator 170 |
| Discharge self-care score | 54.61% |
53.69%
0.9 pts better
|
Numerator 77 · Denominator 141 |
| Discharge mobility score | 54.61% |
50.94%
3.7 pts better
|
Numerator 77 · Denominator 141 |
| Pressure ulcers or injuries, new or worsened | 2.35% |
2.29%
0.1 pts worse
|
Numerator 4 · Denominator 170 · Adjusted rate 3.54% |
| Healthcare-associated infections requiring hospitalization | 6.77% |
7.12%
0.4 pts better
|
No Different than the National Rate · Eligible stays 144 · Observed rate 5.56% · Lower 95% interval 4.19% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 40 |
| Staff flu vaccination coverage | 82.86% |
42%
40.9 pts better
|
Numerator 29 · Denominator 35 |
| Discharge function score | 51.06% |
56.45%
5.4 pts worse
|
Numerator 72 · Denominator 141 |
| Transfer of health information to provider | 98.25% |
95.95%
2.3 pts better
|
Numerator 56 · Denominator 57 |
| Transfer of health information to patient | 98.21% |
96.28%
1.9 pts better
|
Numerator 110 · Denominator 112 |
| Resident COVID-19 vaccinations up to date | 29.21% |
25.2%
4 pts better
|
Numerator 26 · Denominator 89 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
83.8%
11.7 pts better
|
81.7%
13.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 83.2% · Q2 98.3% · Q3 99.2% · Q4 99.3% · 4Q avg 95.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.1% |
13.9%
7.8 pts better
|
12.0%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.1% · Observed 5.2% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.8%
1.8 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.6% |
83.6%
14 pts better
|
79.7%
17.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.5% |
24.5%
4 pts better
|
23.9%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.5% · Observed 15.7% · Expected 18.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-07-02 · Fire 2019-07-02
5 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2018-06-13 · Fire 2018-06-13
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-23
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2026-02-12
D · Potential for more than minimal harm
2019-07-02
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-08-07
D · Potential for more than minimal harm
2019-07-02
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 2019-09-03
D · Potential for more than minimal harm
2019-07-02
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 2019-09-05
D · Potential for more than minimal harm
2019-07-02
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2019-07-24
D · Potential for more than minimal harm
2019-07-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-08-16
F · Potential for more than minimal harm
2018-06-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2018-07-28
Penalties and ownership
What sits behind the stars
Ownership
Baptist Healthcare System Inc
5% Or Greater Direct Ownership Interest · Organization
Baptist Healthcare System Inc
Operational/Managerial Control · Organization
Carrico, Richard
Operational/Managerial Control · Individual
Carrico, Richard
Corporate Officer · Individual
Carrico, Thomas
Operational/Managerial Control · Individual
Colman, Gerard
Operational/Managerial Control · Individual
Colman, Gerard
Corporate Officer · Individual
Diaz, Lewis
Corporate Director · Individual
Falvey, Patrick
Corporate Officer · Individual
Ferriell, James
Operational/Managerial Control · Individual
Fink, Susan
Operational/Managerial Control · Individual
Fultz, William
Corporate Director · Individual
Godfrey, John
Operational/Managerial Control · Individual
Hawley, Kirsten
Corporate Director · Individual
Hicks, Cory
Corporate Director · Individual
Hook, Robert
Corporate Director · Individual
Malik, Raza
Operational/Managerial Control · Individual
Mcpherson, Cora
Operational/Managerial Control · Individual
Morehead, Ashley
Operational/Managerial Control · Individual
Morris, Dwain
Corporate Director · Individual
Norton, Janet
Operational/Managerial Control · Individual
Norton, Janet
Corporate Officer · Individual
O'hair, Daniel
Corporate Director · Individual
Peace, Sandra
Operational/Managerial Control · Individual
Ramey, Robert
Operational/Managerial Control · Individual
Ramey, Robert
Corporate Officer · Individual
Redditt, Alan
Corporate Director · Individual
Shircliff, William
Corporate Director · Individual
Stith, Bonnie
Corporate Director · Individual
Thomas Kuerzi, Jennifer
Corporate Director · Individual
Thomas, Linda
Corporate Director · Individual
Westbrook, Jonathan
Corporate Director · Individual
Woods, Jennifer
Operational/Managerial Control · Individual
Zimmerman, Tammy
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Signature Healthcare at North Hardin Rehab & Welln
Radcliff, KY
3-star overall rating with 2-star inspections with 8 recent health deficiencies
#2
Signature Healthcare of Elizabethtown
Elizabethtown, KY
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Elizabethtown Nursing and Rehabilitation Center
Elizabethtown, KY
1-star overall rating with 2-star inspections with $4,893 in total fines with 8 recent health deficiencies
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