Cycle 1
Health 2025-08-22 · Fire 2025-08-22
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Elsmere, KY
Emerald Trace
2-star overall rating with 2-star inspections with $9,318 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
3802 Turkeyfoot Road, Elsmere, KY
(859) 342-0200
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
54
Certified beds
Average residents
45
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2017-02-23
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
0.67
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.82
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
3.68
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
6.18
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
2.49
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
5.62
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.22
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.67
CMS adjusted RN staffing hours
Adjusted total hours
6.22
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
71%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,010
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25
Composite VBP score used to determine payment impact.
Payment multiplier
0.9836
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.84% · Performance 22.50% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 8.39% · Performance 8.40% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 60.66% · Performance 67.57% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
10
Baseline 6.42 hours · Performance 6.16 hours · Measure score 10 · Achievement 10 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.97% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 410 · Observed rate 12.68% · Lower 95% interval 9.65% |
| Discharge to community | 46% |
50.57%
4.6 pts worse
|
Worse than the National Rate · Eligible stays 443 · Observed rate 39.05% · Lower 95% interval 41.33% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.56% |
95.27%
3.3 pts better
|
Numerator 205 · Denominator 208 |
| Falls with major injury | 0.96% |
0.77%
0.2 pts worse
|
Numerator 2 · Denominator 208 |
| Discharge self-care score | 56.94% |
53.69%
3.2 pts better
|
Numerator 82 · Denominator 144 |
| Discharge mobility score | 40.97% |
50.94%
10 pts worse
|
Numerator 59 · Denominator 144 |
| Pressure ulcers or injuries, new or worsened | 2.4% |
2.29%
0.1 pts worse
|
Numerator 5 · Denominator 208 · Adjusted rate 3.12% |
| Healthcare-associated infections requiring hospitalization | 8.4% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 208 · Observed rate 9.62% · Lower 95% interval 5.95% |
| Staff COVID-19 vaccination coverage | 1.16% |
8.2%
7 pts worse
|
Numerator 1 · Denominator 86 |
| Staff flu vaccination coverage | 20.75% |
42%
21.2 pts worse
|
Numerator 33 · Denominator 159 |
| Discharge function score | 56.94% |
56.45%
0.5 pts better
|
Numerator 82 · Denominator 144 |
| Transfer of health information to provider | 92.41% |
95.95%
3.5 pts worse
|
Numerator 73 · Denominator 79 |
| Transfer of health information to patient | 92.92% |
96.28%
3.4 pts worse
|
Numerator 105 · Denominator 113 |
| Resident COVID-19 vaccinations up to date | 24.77% |
25.2%
0.4 pts worse
|
Numerator 27 · Denominator 109 |
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 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
2.2
0.2 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.0 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.3%
5.7 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.2%
3.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 8.5% |
3.8%
4.7 pts worse
|
3.3%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 12.0% · Q3 9.1% · Q4 9.1% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.5% |
15.2%
10.7 pts better
|
11.4%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 4.5% · Q3 0.0% · Q4 0.0% · 4Q avg 4.5% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
6.7%
2.7 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.5% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.8% |
29.6%
6.8 pts better
|
19.6%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 28.6% · 4Q avg 22.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.6% |
17.6%
11 pts worse
|
16.7%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 28.6% · 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 | 13.1% |
17.3%
4.2 pts better
|
16.3%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.1% |
15.6%
4.5 pts better
|
14.9%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 23.8% · 4Q avg 11.1% · 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% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
1.7%
0.5 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 0.0% · Q3 4.5% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.1% |
19.8%
3.3 pts worse
|
19.8%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 16.5% · Q3 46.3% · 4Q avg 23.1% |
| Percentage of long-stay residents with pressure ulcers | 8.1% |
5.5%
2.6 pts worse
|
5.1%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 11.9% · Q3 8.7% · Q4 6.8% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
83.8%
15.3 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 99.1% · Q3 99.0% · Q4 99.5% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.0% |
13.9%
1.1 pts worse
|
12.0%
3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.0% · Observed 15.0% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.8%
0.4 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.9% · Q3 1.5% · Q4 0.8% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.3% |
83.6%
13.7 pts better
|
79.7%
17.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 35.3% |
24.5%
10.8 pts worse
|
23.9%
11.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 35.3% · Observed 32.9% · Expected 22.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-15 · Fire 2023-12-15
4 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2021-10-01 · Fire 2021-10-01
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
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
2025-08-22
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-10-17
E · Potential for more than minimal harm
2025-08-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-10-17
F · Potential for more than minimal harm
2023-12-15
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-12-21
F · Potential for more than minimal harm
2023-12-15
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-12-21
F · Potential for more than minimal harm
2023-12-15
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-12-21
F · Potential for more than minimal harm
2023-12-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-12-21
F · Potential for more than minimal harm
2023-12-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-21
D · Potential for more than minimal harm
2023-12-15
K222 · Egress Deficiencies
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 2023-12-21
D · Potential for more than minimal harm
2023-12-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-21
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-22
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-10-17
E · Potential for more than minimal harm
2025-08-22
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 2025-09-26
J · Immediate jeopardy
2023-12-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-16
G · Actual harm
2023-12-15
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 2024-01-16
E · Potential for more than minimal harm
2023-12-15
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 2024-01-16
E · Potential for more than minimal harm
2023-12-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-16
D · Potential for more than minimal harm
2023-12-15
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 2024-01-16
E · Potential for more than minimal harm
2021-10-01
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 2021-10-22
Penalties and ownership
What sits behind the stars
$9,318
2023-12-15
Fine
Fine · fine $9,318
Fine
Ownership
Kenton Housing, Inc.
5% Or Greater Direct Ownership Interest · Organization
Eldridge, John
Corporate Director · Individual
Foster, Terry
Corporate Director · Individual
Halderman, Bonnie
Corporate Director · Individual
Jones, Julie
Corporate Director · Individual
Keith, Ronald
Corporate Director · Individual
Keith, Ronald
Corporate Officer · Individual
Kenton Housing, Inc.
Operational/Managerial Control · Organization
Knollman, Londa
Operational/Managerial Control · Individual
Knollman, Londa
Corporate Officer · Individual
Knollman, Londa
W-2 Managing Employee · Individual
Middendorf, Mark
Corporate Director · Individual
Middendorf, Mark
Corporate Officer · Individual
Middleton, John
Corporate Director · Individual
Middleton, John
Corporate Officer · Individual
Schieman, Eric
Corporate Director · Individual
Shabazz, Tiffany
Corporate Director · Individual
Simmons, Kelly
Corporate Director · Individual
Weaver, Paul
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Woodcrest Nursing and Rehabilitation Center
Elsmere, KY
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
St Elizabeth Edgewood SNF
Edgewood, KY
5-star overall rating with 4-star inspections with 1 recent health deficiencies
#3
Florence Park Care Center
Florence, KY
1-star overall rating with 1-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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