Cycle 1
Health 2025-05-08 · Fire 2025-05-08
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Albany, KY
Clinton County Care and Rehabilitation Center
4-star overall rating with 4-star inspections with 1 recent health deficiencies
404 North Washington Street, Albany, KY
(606) 387-6623
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
52
Certified beds
Average residents
47
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Signature Healthcare
Operator or chain grouping
Approved since
1991-12-16
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
0.53
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.44
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
1.91
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.88
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.97
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.39
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.48
CMS adjusted RN staffing hours
Adjusted total hours
3.56
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
23%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,056
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.55
Composite VBP score used to determine payment impact.
Payment multiplier
0.9908
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
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
0
Baseline 6.71% · Performance 8.05% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
10
Baseline 22.73% · Performance 21.74% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
1.26
Baseline 3.69 hours · Performance 3.44 hours · Measure score 1.26 · Achievement 1.26 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.55% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 67 · Observed rate 17.91% · Lower 95% interval 9.08% |
| Discharge to community | 36.29% |
50.57%
14.3 pts worse
|
Worse than the National Rate · Eligible stays 59 · Observed rate 25.42% · Lower 95% interval 26.79% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 96.97% |
95.27%
1.7 pts better
|
Numerator 32 · Denominator 33 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 33 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 6.06% |
2.29%
3.8 pts worse
|
Numerator 2 · Denominator 33 · Adjusted rate 5.48% |
| Healthcare-associated infections requiring hospitalization | 8.05% |
7.12%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 25 · Observed rate 12% · Lower 95% interval 3.98% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 62 |
| Staff flu vaccination coverage | 12% |
42%
30 pts worse
|
Numerator 9 · Denominator 75 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 10% |
25.2%
15.2 pts worse
|
Numerator 2 · Denominator 20 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.9
0.2 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.7 |
2.2
2.5 pts worse
|
1.8
2.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.7 · Observed 4.3 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.9% |
94.3%
6.4 pts worse
|
93.4%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.3% · Q2 87.8% · Q3 81.4% · Q4 88.6% · 4Q avg 87.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.7% |
96.2%
0.5 pts worse
|
95.5%
0.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 9.2% |
3.8%
5.4 pts worse
|
3.3%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 9.8% · Q3 9.3% · Q4 6.8% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 42.0% |
15.2%
26.8 pts worse
|
11.4%
30.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 55.3% · Q3 48.8% · Q4 47.4% · 4Q avg 42.0% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
6.7%
2.2 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 5.4% · Q3 5.3% · Q4 2.6% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.2% |
29.6%
3.4 pts better
|
19.6%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 27.5% · Q3 26.8% · Q4 26.8% · 4Q avg 26.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.2% |
17.6%
4.4 pts better
|
16.7%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 13.9% · Q3 11.4% · Q4 8.6% · 4Q avg 13.2% · 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 | 4.1% |
17.3%
13.2 pts better
|
16.3%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.5% |
15.6%
10.1 pts better
|
14.9%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.1% · Q3 5.4% · Q4 5.6% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.7%
1.1 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.4% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.6% |
19.8%
0.2 pts better
|
19.8%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 28.4% · Q2 18.7% · Q3 21.5% · Q4 9.6% · 4Q avg 19.6% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
5.5%
1.9 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 5.9% · Q3 0.0% · Q4 0.0% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.6% |
83.8%
5.8 pts better
|
81.7%
7.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 72.7% · Q2 85.7% · Q3 100.0% · Q4 96.3% · 4Q avg 89.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.4% |
13.9%
4.5 pts better
|
12.0%
2.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.4% · Observed 10.3% · Expected 12.3% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.1% |
83.6%
9.5 pts better
|
79.7%
13.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 44.5% |
24.5%
20 pts worse
|
23.9%
20.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 44.5% · Observed 37.9% · Expected 20.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-12-22 · Fire 2021-12-22
7 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2019-04-11 · Fire 2019-04-11
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2021-12-22
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2022-01-31
F · Potential for more than minimal harm
2021-12-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-12-31
E · Potential for more than minimal harm
2021-12-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-01-17
D · Potential for more than minimal harm
2021-12-22
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-01-31
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-08
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 2025-06-04
F · Potential for more than minimal harm
2021-12-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-01-31
E · Potential for more than minimal harm
2021-12-22
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-01-31
D · Potential for more than minimal harm
2021-12-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-01-31
D · Potential for more than minimal harm
2021-12-22
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-01-31
D · Potential for more than minimal harm
2021-12-22
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-01-31
D · Potential for more than minimal harm
2021-12-22
F690 · Quality of Life and Care Deficiencies
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 2022-01-31
D · Potential for more than minimal harm
2021-12-22
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 2022-01-31
Penalties and ownership
What sits behind the stars
Ownership
Lp Cs Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Agemo Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Harrison, John
Corporate Officer · Individual
Jjla LLC
5% Or Greater Indirect Ownership Interest · Organization
Lee, Donna
Operational/Managerial Control · Individual
Lpsnf Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Smedra, Ira
5% Or Greater Indirect Ownership Interest · Individual
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
Pickett Care And Rehabilitation Center
Byrdstown, TN
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Cumberland Valley Nursing & Rehabilitation Center
Burkesville, KY
1-star overall rating with 2-star inspections with $24,385 in total fines with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Mountain Ridge Health and Rehabilitation
Monticello, KY
1-star overall rating with 1-star inspections with $13,426 in total fines with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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