Cycle 1
Health 2023-02-12 · Fire 2023-02-12
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Louisville, KY
Home of the Innocents
2-star overall rating with 1-star inspections with 8 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
1100 East Market Street, Louisville, KY
(502) 596-1000
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
76
Certified beds
Average residents
73
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1978-06-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
2.50
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
2.19
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
4.08
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
8.77
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
4.69
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
7.12
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
1.43
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.42
CMS adjusted RN staffing hours
Adjusted total hours
4.97
CMS adjusted total nurse staffing hours
Case-mix index
2.41
Higher values indicate more complex resident acuity
RN turnover
10%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
21%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
100
Composite VBP score used to determine payment impact.
Payment multiplier
1.0278
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
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
10
Performance 23.78% · Measure score 10 · Achievement 10 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
10
Baseline 3.22 hours · Performance 5.80 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
No data were submitted for this measure. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 480 |
| Staff flu vaccination coverage | 95.47% |
42%
53.5 pts better
|
Numerator 674 · Denominator 706 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
94.3%
4.3 pts better
|
93.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.6% · Q3 95.8% · Q4 100.0% · 4Q avg 98.6% |
| 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 | 0.7% |
3.8%
3.1 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
15.2%
15.2 pts better
|
11.4%
11.4 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 who lose too much weight | 3.5% |
6.7%
3.2 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 4.1% · Q3 4.2% · Q4 2.8% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 82.3% |
29.6%
52.7 pts worse
|
19.6%
62.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 82.2% · Q2 83.6% · Q3 83.1% · Q4 80.3% · 4Q avg 82.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.7% |
17.6%
2.9 pts better
|
16.7%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 16.1% · Q3 12.1% · Q4 15.0% · 4Q avg 14.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 21.1% |
0.2%
20.9 pts worse
|
0.1%
21 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 20.5% · Q3 18.3% · Q4 19.7% · 4Q avg 21.1% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.9% |
17.3%
9.4 pts better
|
16.3%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.7% |
15.6%
6.1 pts worse
|
14.9%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.7%
0.6 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.4% · Q3 1.0% · Q4 1.2% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.2% |
1.7%
2.5 pts worse
|
1.7%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 1.4% · Q3 7.0% · Q4 4.2% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 2.4% |
19.8%
17.4 pts better
|
19.8%
17.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 1.9% · Q3 1.9% · Q4 1.8% · 4Q avg 2.4% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
5.5%
2.5 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 6.1% · Q3 1.1% · Q4 3.4% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.4% |
83.8%
12.4 pts worse
|
81.7%
10.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 71.4% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-31 · Fire 2019-10-31
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2018-08-30 · Fire 2018-08-30
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-02-12
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2023-03-31
F · Potential for more than minimal harm
2023-02-12
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-03-31
F · Potential for more than minimal harm
2023-02-12
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2023-03-31
F · Potential for more than minimal harm
2023-02-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-31
F · Potential for more than minimal harm
2023-02-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-31
F · Potential for more than minimal harm
2023-02-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-03-31
F · Potential for more than minimal harm
2023-02-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-31
F · Potential for more than minimal harm
2023-02-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-31
E · Potential for more than minimal harm
2023-02-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-03-31
D · Potential for more than minimal harm
2023-02-12
K321 · Smoke Deficiencies
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 2023-03-31
D · Potential for more than minimal harm
2023-02-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-03-31
E · Potential for more than minimal harm
2019-10-31
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-12-12
D · Potential for more than minimal harm
2019-10-31
K321 · Smoke Deficiencies
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 2019-12-12
D · Potential for more than minimal harm
2019-10-31
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-12-12
F · Potential for more than minimal harm
2018-08-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2018-09-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-09-13
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2025-10-29
D · Potential for more than minimal harm
2025-09-13
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-10-29
D · Potential for more than minimal harm
2025-09-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-10-29
D · Potential for more than minimal harm
2025-09-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-29
J · Immediate jeopardy
2023-02-12
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 2023-04-13
J · Immediate jeopardy
2023-02-12
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 2023-04-13
E · Potential for more than minimal harm
2023-02-12
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-04-13
E · Potential for more than minimal harm
2023-02-12
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 2023-04-01
F · Potential for more than minimal harm
2019-10-31
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 2019-12-31
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
Kindred Hospital - Louisville
Louisville, KY
2-star overall rating with 2-star inspections with $64,799 in total fines with 3 recent health deficiencies
#2
Nazareth Home Clifton
Louisville, KY
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Sycamore Heights Health and Rehabilitation
Louisville, KY
1-star overall rating with 1-star inspections with $21,879 in total fines with 9 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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