Cycle 1
Health 2025-07-25 · Fire 2025-07-25
3 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Lexington, KY
Bluegrass Care & Rehabilitation Center
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
3576 Pimlico Parkway, Lexington, KY
(859) 272-0608
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
124
Certified beds
Average residents
109
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Signature Healthcare
Operator or chain grouping
Approved since
2000-09-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
71 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
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
0.64
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.17
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.52
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
2.99
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.60
CMS adjusted RN staffing hours
Adjusted total hours
3.32
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,213
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.62
Composite VBP score used to determine payment impact.
Payment multiplier
0.9878
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.16
Baseline 21.22% · Performance 19.04% · Measure score 5.16 · Achievement 5.16 · Improvement 4.70
Healthcare-associated infections
0
Baseline 7.41% · Performance 7.95% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.90
Baseline 51.48% · Performance 35.48% · Measure score 6.90 · Achievement 6.90 · Improvement 5.51
Adjusted total nurse staffing
1.39
Baseline 3.47 hours · Performance 3.47 hours · Measure score 1.39 · Achievement 1.39 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.08% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 160 · Observed rate 15% · Lower 95% interval 8.96% |
| Discharge to community | 61.33% |
50.57%
10.8 pts better
|
Better than the National Rate · Eligible stays 149 · Observed rate 49.66% · Lower 95% interval 50.91% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 95.83% |
95.27%
0.6 pts better
|
Numerator 92 · Denominator 96 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 96 |
| Discharge self-care score | 58.62% |
53.69%
4.9 pts better
|
Numerator 34 · Denominator 58 |
| Discharge mobility score | 43.1% |
50.94%
7.8 pts worse
|
Numerator 25 · Denominator 58 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 96 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.96% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 99 · Observed rate 10.1% · Lower 95% interval 5.43% |
| Staff COVID-19 vaccination coverage | 0.94% |
8.2%
7.3 pts worse
|
Numerator 1 · Denominator 106 |
| Staff flu vaccination coverage | 18.93% |
42%
23.1 pts worse
|
Numerator 32 · Denominator 169 |
| Discharge function score | 60.34% |
56.45%
3.9 pts better
|
Numerator 35 · Denominator 58 |
| Transfer of health information to provider | 92.86% |
95.95%
3.1 pts worse
|
Numerator 39 · Denominator 42 |
| Transfer of health information to patient | 95.45% |
96.28%
0.8 pts worse
|
Numerator 42 · Denominator 44 |
| Resident COVID-19 vaccinations up to date | 25% |
25.2%
0.2 pts worse
|
Numerator 14 · Denominator 56 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.9
0.5 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.6 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
2.2
0.7 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.8 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 82.4% |
94.3%
11.9 pts worse
|
93.4%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 83.5% · Q2 65.1% · Q3 88.2% · Q4 92.9% · 4Q avg 82.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.1% |
96.2%
6.1 pts worse
|
95.5%
5.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.5% |
3.8%
0.3 pts better
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 5.9% · Q4 7.1% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 14.1% |
15.2%
1.1 pts better
|
11.4%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 17.3% · Q3 12.5% · Q4 23.6% · 4Q avg 14.1% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
6.7%
0.6 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 10.1% · Q3 2.6% · Q4 8.8% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.5% |
29.6%
19.1 pts better
|
19.6%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 9.9% · Q3 11.4% · Q4 11.0% · 4Q avg 10.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.6% |
17.6%
8 pts better
|
16.7%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 9.4% · Q3 8.6% · Q4 9.4% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.8% |
17.3%
4.5 pts worse
|
16.3%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.0% |
15.6%
0.6 pts better
|
14.9%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.1% · Q2 18.1% · Q3 1.4% · Q4 5.3% · 4Q avg 15.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.7%
0.5 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
1.7%
0.8 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 0.0% · Q4 1.2% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.0% |
19.8%
5.2 pts worse
|
19.8%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.0% · Q2 20.9% · Q3 25.8% · Q4 21.3% · 4Q avg 25.0% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
5.5%
1.3 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 4.9% · Q3 3.7% · Q4 4.6% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 75.4% |
83.8%
8.4 pts worse
|
81.7%
6.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 68.9% · Q2 63.3% · Q3 78.1% · Q4 90.0% · 4Q avg 75.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.9% |
13.9%
2 pts worse
|
12.0%
3.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.9% · Observed 18.5% · Expected 13.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.8%
0.6 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 2.1% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 69.6% |
83.6%
14 pts worse
|
79.7%
10.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.9% |
24.5%
1.6 pts better
|
23.9%
1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.9% · Observed 26.9% · Expected 27.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-30 · Fire 2024-08-30
5 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2019-11-21 · Fire 2019-11-21
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-07-25
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-07-25
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-08-15
F · Potential for more than minimal harm
2024-08-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-10
F · Potential for more than minimal harm
2019-11-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-01-05
F · Potential for more than minimal harm
2019-11-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-01-05
D · Potential for more than minimal harm
2019-11-21
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2020-01-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-19
D · Potential for more than minimal harm
2025-07-25
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-08-19
D · Potential for more than minimal harm
2025-07-25
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-08-19
E · Potential for more than minimal harm
2024-08-30
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 2024-09-26
D · Potential for more than minimal harm
2024-08-30
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 2024-09-26
D · Potential for more than minimal harm
2024-08-30
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-30
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-26
E · Potential for more than minimal harm
2019-11-21
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 2020-01-05
D · Potential for more than minimal harm
2019-11-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-01-05
D · Potential for more than minimal harm
2019-11-21
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2020-01-05
Penalties and ownership
What sits behind the stars
Ownership
Shc LP Holdings Ii LLC
5% Or Greater Direct Ownership Interest · Organization
Harrison, John
Corporate Officer · Individual
Jjla LLC
5% Or Greater Indirect Ownership Interest · Organization
Lpsnf LLC
5% Or Greater Indirect Ownership Interest · Organization
Phillips, Ann
W-2 Managing Employee · Individual
Smedra, Ira
5% Or Greater Indirect Ownership Interest · Individual
Spring Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Steier Iii, Elmer
5% Or Greater Indirect Ownership Interest · Individual
Wheaten LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Hartland Park Health & Rehabilitation
Lexington, KY
1-star overall rating with 2-star inspections with $12,925 in total fines with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Mayfair Manor
Lexington, KY
1-star overall rating with 1-star inspections with abuse icon flag with $33,602 in total fines with 5 recent health deficiencies
#3
Sayre Christian Village Nursing Home
Lexington, KY
2-star overall rating with 3-star inspections with $7,901 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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