Cycle 1
Health 2025-03-06 · Fire 2025-03-06
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Winchester, KY
Fountain Circle Care & Rehabilitation Center
2-star overall rating with 2-star inspections with 4 recent health deficiencies
200 Glenway Road, Winchester, KY
(859) 744-1800
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
147
Certified beds
Average residents
132
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Signature Healthcare
Operator or chain grouping
Approved since
1978-03-01
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
0.62
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.28
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.85
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.23
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.59
CMS adjusted RN staffing hours
Adjusted total hours
3.69
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,092
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.05
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.28% · Performance 23.33% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.53
Baseline 7.07% · Performance 7.38% · Measure score 1.53 · Achievement 1.53 · Improvement 0
Total nurse turnover
3.52
Baseline 43.80% · Performance 49.31% · Measure score 3.52 · Achievement 3.52 · Improvement 0
Adjusted total nurse staffing
2.17
Baseline 3.36 hours · Performance 3.70 hours · Measure score 2.17 · Achievement 2.17 · Improvement 0.87
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.56% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 183 · Observed rate 15.3% · Lower 95% interval 8.47% |
| Discharge to community | 59.62% |
50.57%
9 pts better
|
No Different than the National Rate · Eligible stays 166 · Observed rate 47.59% · Lower 95% interval 49.36% |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.62% |
95.27%
2.4 pts better
|
Numerator 82 · Denominator 84 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 84 |
| Discharge self-care score | 49.15% |
53.69%
4.5 pts worse
|
Numerator 29 · Denominator 59 |
| Discharge mobility score | 57.63% |
50.94%
6.7 pts better
|
Numerator 34 · Denominator 59 |
| Pressure ulcers or injuries, new or worsened | 2.38% |
2.29%
0.1 pts worse
|
Numerator 2 · Denominator 84 · Adjusted rate 1.99% |
| Healthcare-associated infections requiring hospitalization | 7.38% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 104 · Observed rate 8.65% · Lower 95% interval 4.3% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 132 |
| Staff flu vaccination coverage | 19.23% |
42%
22.8 pts worse
|
Numerator 40 · Denominator 208 |
| Discharge function score | 64.41% |
56.45%
8 pts better
|
Numerator 38 · Denominator 59 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 97.62% |
96.28%
1.3 pts better
|
Numerator 41 · Denominator 42 |
| Resident COVID-19 vaccinations up to date | 41.18% |
25.2%
16 pts better
|
Numerator 14 · Denominator 34 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.9
0.1 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.8 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 7.6 |
2.2
5.4 pts worse
|
1.8
5.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 7.6 · Observed 7.8 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 55.1% |
94.3%
39.2 pts worse
|
93.4%
38.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 50.4% · Q2 55.9% · Q3 58.4% · Q4 55.6% · 4Q avg 55.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 71.7% |
96.2%
24.5 pts worse
|
95.5%
23.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 71.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
3.8%
0.7 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.5% · Q3 5.3% · Q4 6.0% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 13.3% |
15.2%
1.9 pts better
|
11.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 8.6% · Q3 6.9% · Q4 32.3% · 4Q avg 13.3% |
| Percentage of long-stay residents who lose too much weight | 11.0% |
6.7%
4.3 pts worse
|
5.4%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 13.9% · Q3 12.3% · Q4 8.0% · 4Q avg 11.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.7% |
29.6%
1.1 pts worse
|
19.6%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 29.1% · Q3 32.4% · Q4 33.6% · 4Q avg 30.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.5% |
17.6%
6.1 pts better
|
16.7%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 11.5% · Q3 7.0% · Q4 13.0% · 4Q avg 11.5% · 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 | 10.0% |
17.3%
7.3 pts better
|
16.3%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 0.0% · Q3 16.0% · Q4 4.6% · 4Q avg 10.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.8% |
15.6%
2.8 pts better
|
14.9%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 16.2% · Q3 10.8% · Q4 10.9% · 4Q avg 12.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.7%
0.3 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.6% · Q3 0.6% · Q4 0.6% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.7%
About the same
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.7% · Q3 2.7% · Q4 1.7% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.7% |
19.8%
1.1 pts better
|
19.8%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 19.8% · Q3 14.3% · Q4 19.8% · 4Q avg 18.7% |
| Percentage of long-stay residents with pressure ulcers | 8.5% |
5.5%
3 pts worse
|
5.1%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 13.2% · Q3 5.3% · Q4 5.0% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.2% |
83.8%
2.4 pts better
|
81.7%
4.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.5% · Q2 83.8% · Q3 86.7% · Q4 85.7% · 4Q avg 86.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 26.9% |
13.9%
13 pts worse
|
12.0%
14.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.9% · Observed 29.9% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.8%
0.5 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.4% · Q3 2.3% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 77.1% |
83.6%
6.5 pts worse
|
79.7%
2.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 77.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.2% |
24.5%
7.7 pts worse
|
23.9%
8.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.2% · Observed 36.4% · Expected 26.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-12-19 · Fire 2019-12-19
4 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2018-11-14 · Fire 2018-11-14
3 health deficiencies
Top issue: Administration (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2019-12-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-01-08
D · Potential for more than minimal harm
2019-12-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2020-01-08
D · Potential for more than minimal harm
2019-12-19
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 2020-01-08
E · Potential for more than minimal harm
2018-11-14
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2018-11-30
D · Potential for more than minimal harm
2018-11-14
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2018-12-17
D · Potential for more than minimal harm
2018-11-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-11-30
D · Potential for more than minimal harm
2018-11-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2018-11-30
D · Potential for more than minimal harm
2018-11-14
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2018-11-30
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-06
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2025-04-04
F · Potential for more than minimal harm
2025-03-06
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 2025-04-04
E · Potential for more than minimal harm
2025-03-06
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 2025-04-04
E · Potential for more than minimal harm
2025-03-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-04
D · Potential for more than minimal harm
2019-12-19
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2020-01-08
D · Potential for more than minimal harm
2019-12-19
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2020-01-08
D · Potential for more than minimal harm
2019-12-19
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 2020-01-08
D · Potential for more than minimal harm
2019-12-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-01-08
E · Potential for more than minimal harm
2018-11-14
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 2018-12-01
E · Potential for more than minimal harm
2018-11-14
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2018-12-01
D · Potential for more than minimal harm
2018-11-14
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2018-12-01
Penalties and ownership
What sits behind the stars
Ownership
Shc Ky Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Asbr Holdings LLC
5% Or Greater Indirect 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
Shc LP Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Signature Healthcare LLC
Operational/Managerial Control · Organization
Simpson, Cynthia
W-2 Managing Employee · Individual
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
The Willows at Hamburg
Lexington, KY
3-star overall rating with 2-star inspections with $61,627 in total fines with 2 recent health deficiencies
#2
Lexington Premier Nursing & Rehab
Lexington, KY
1-star overall rating with 1-star inspections with $240,331 in total fines with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Bourbon Heights Nursing Home
Paris, KY
1-star overall rating with 1-star inspections with $57,841 in total fines with 10 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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