23 health deficiencies
Top issue: Nutrition and Dietary (5 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Louisville, KY
1-star overall rating with 1-star inspections with Special Focus status with $306,141 in total fines with 23 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
1015 West Magazine Street, Louisville, KY
(502) 815-6460
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
92
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lyon Healthcare
Operator or chain grouping
Approved since
2012-04-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 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
RN hours / resident day
0.51
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
1.92
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.21
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.28
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
2.87
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
2.76
CMS adjusted total nurse staffing hours
Case-mix index
1.59
Higher values indicate more complex resident acuity
RN turnover
92%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
75%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
13,490
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
4.56
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 63.27% · Performance 70.19% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.91
Baseline 2.21 hours · Performance 2.71 hours · Measure score 0.91 · Achievement 0 · Improvement 0.91
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.38% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 10.71% · Lower 95% interval 6.92% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.76 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 20 · Denominator 20 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 20 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 5% |
2.29%
2.7 pts worse
|
Numerator 1 · Denominator 20 · Adjusted rate 4.02% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.1% |
8.2%
7.1 pts worse
|
Numerator 1 · Denominator 91 |
| Staff flu vaccination coverage | 18.45% |
42%
23.6 pts worse
|
Numerator 31 · Denominator 168 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.9
About the same
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.7 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
2.2
About the same
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.0 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 46.7% |
94.3%
47.6 pts worse
|
93.4%
46.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.9% · Q2 39.2% · Q3 36.6% · Q4 64.2% · 4Q avg 46.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.6% |
96.2%
2.6 pts worse
|
95.5%
1.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.3% |
3.8%
1.5 pts worse
|
3.3%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 5.4% · Q3 5.6% · Q4 6.0% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 18.2% |
15.2%
3 pts worse
|
11.4%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 20.6% · Q3 10.8% · Q4 15.3% · 4Q avg 18.2% |
| Percentage of long-stay residents who lose too much weight | 10.4% |
6.7%
3.7 pts worse
|
5.4%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 8.2% · Q3 13.0% · Q4 7.6% · 4Q avg 10.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.6% |
29.6%
15 pts better
|
19.6%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 12.2% · Q3 17.4% · Q4 15.2% · 4Q avg 14.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.1% |
17.6%
5.5 pts worse
|
16.7%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.4% · Q2 22.9% · Q3 25.0% · Q4 20.9% · 4Q avg 23.1% · 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 | 0.0% |
17.3%
17.3 pts better
|
16.3%
16.3 pts better
|
Long 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 long-stay residents whose need for help with daily activities has increased | 0.8% |
15.6%
14.8 pts better
|
14.9%
14.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.7%
0.4 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
1.7%
0.6 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.9% |
19.8%
2.1 pts worse
|
19.8%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 17.6% · Q3 15.8% · Q4 34.2% · 4Q avg 21.9% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
5.5%
0.7 pts better
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 6.2% · Q3 4.6% · Q4 5.6% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 44.4% |
83.8%
39.4 pts worse
|
81.7%
37.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 67.9% · Q2 58.5% · Q3 27.0% · Q4 19.1% · 4Q avg 44.4% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.8% |
1.8%
1 pts worse
|
1.6%
1.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 4.3% · Q3 3.8% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 53.7% |
83.6%
29.9 pts worse
|
79.7%
26 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 53.7% |
Survey summary
Top issue: Nutrition and Dietary (5 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Environmental (1 deficiency)
3 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Top issue: Nutrition and Dietary (4 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2023-08-30
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-12
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-30
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-08-30
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-08-30
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-30
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-20
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-08-30
Fire Safety
Have a properly installed and maintained dumbwaiter or escalator.
Corrected 2023-08-30
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-20
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-08-30
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-30
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-08-30
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2020-01-31
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2020-01-31
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-01-31
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2018-11-30
Inspection history
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-04-29
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-04-29
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-12-23
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-01-03
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-01-03
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-08
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-08-30
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-08
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-08-30
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-08-30
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-08-30
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-30
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-08-30
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-08-30
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-08-30
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2023-08-30
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-30
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2023-08-30
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-08-30
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-08-30
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-08-30
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-08-30
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-08-30
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-08-30
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 2023-08-30
Health
Keep all essential equipment working safely.
Corrected 2023-08-30
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2020-01-31
Health
Keep all essential equipment working safely.
Corrected 2020-01-31
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-01-31
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2020-01-31
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 2020-01-31
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2018-12-01
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2018-12-01
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2018-12-01
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2018-12-01
Health
Provide and implement an infection prevention and control program.
Corrected 2018-12-01
Penalties and ownership
Fine · fine $306,141
Fine
Payment Denial · denial start 2023-08-10 · 146 days
146 day denial
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Louisville, KY
1-star overall rating with 2-star inspections with 6 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
Louisville, KY
2-star overall rating with 1-star inspections with $16,724 in total fines with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
Louisville, KY
2-star overall rating with 1-star inspections with 8 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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