Cycle 1
Health 2025-05-16 · Fire 2025-05-16
3 health deficiencies
Top issue: Infection Control (1 deficiency)
8 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Louisville, KY
Little Sisters of the Poor
2-star overall rating with 3-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
15 Audubon Plaza Drive, Louisville, KY
(502) 636-2300
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
35
Certified beds
Average residents
30
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1991-05-02
CMS approved date
Coverage
Medicare + Medicaid
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
1.36
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.36
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
3.79
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
5.51
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.96
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
1.10
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.73
CMS adjusted RN staffing hours
Adjusted total hours
7.02
CMS adjusted total nurse staffing hours
Case-mix index
1.07
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,362
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
50
Composite VBP score used to determine payment impact.
Payment multiplier
1.0041
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
0
Baseline 52.00% · Performance 68.29% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
10
Baseline 5.80 hours · Performance 7.18 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 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 2 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 1 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 4.82% |
8.2%
3.4 pts worse
|
Numerator 4 · Denominator 83 |
| Staff flu vaccination coverage | 2.22% |
42%
39.8 pts worse
|
Numerator 2 · Denominator 90 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
1.9
0.7 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 1.9 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.2
1.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.1% |
94.3%
1.8 pts better
|
93.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 87.5% · Q2 100.0% · Q3 97.0% · Q4 100.0% · 4Q avg 96.1% |
| 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 | 7.0% |
3.8%
3.2 pts worse
|
3.3%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 6.1% · Q3 9.1% · Q4 12.9% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.5% |
15.2%
6.7 pts better
|
11.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 6.7% · Q3 13.3% · Q4 3.4% · 4Q avg 8.5% |
| Percentage of long-stay residents who lose too much weight | 2.5% |
6.7%
4.2 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 6.5% · Q4 3.4% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.5% |
29.6%
20.1 pts better
|
19.6%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 12.1% · Q3 6.5% · Q4 6.7% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.6% |
17.6%
7 pts worse
|
16.7%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 23.3% · Q3 25.0% · Q4 25.0% · 4Q avg 24.6% · 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 | 31.4% |
17.3%
14.1 pts worse
|
16.3%
15.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 38.4% · Q3 34.0% · 4Q avg 31.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 27.9% |
15.6%
12.3 pts worse
|
14.9%
13 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 18.2% · Q3 41.9% · Q4 28.6% · 4Q avg 27.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
0.7%
0.7 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
1.7%
0.7 pts worse
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.3% · Q3 3.0% · Q4 0.0% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.1% |
19.8%
4.3 pts worse
|
19.8%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 25.1% · Q3 21.5% · Q4 24.0% · 4Q avg 24.1% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
5.5%
2 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 0.0% · Q3 4.1% · Q4 4.9% · 4Q avg 3.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-06-24 · Fire 2022-06-24
4 health deficiencies
Top issue: Administration (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2019-06-05 · Fire 2019-06-05
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-16
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-07-11
F · Potential for more than minimal harm
2025-05-16
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2025-07-11
F · Potential for more than minimal harm
2025-05-16
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-07-11
F · Potential for more than minimal harm
2025-05-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-11
E · Potential for more than minimal harm
2025-05-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-07-11
D · Potential for more than minimal harm
2025-05-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-11
D · Potential for more than minimal harm
2025-05-16
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-07-11
D · Potential for more than minimal harm
2025-05-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-07-11
F · Potential for more than minimal harm
2022-06-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-23
E · Potential for more than minimal harm
2019-06-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-08-17
E · Potential for more than minimal harm
2019-06-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-08-17
D · Potential for more than minimal harm
2019-06-05
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2019-08-17
D · Potential for more than minimal harm
2019-06-05
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 2019-08-17
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-16
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 2025-07-11
D · Potential for more than minimal harm
2025-05-16
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-11
D · Potential for more than minimal harm
2025-05-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-11
F · Potential for more than minimal harm
2022-06-24
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2022-09-03
F · Potential for more than minimal harm
2022-06-24
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2022-09-03
F · Potential for more than minimal harm
2022-06-24
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2022-09-03
D · Potential for more than minimal harm
2022-06-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-09-03
D · Potential for more than minimal harm
2019-06-05
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2019-07-13
D · Potential for more than minimal harm
2019-06-05
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 2019-07-13
D · Potential for more than minimal harm
2019-06-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-07-13
Penalties and ownership
What sits behind the stars
Ownership
Courtney, Maureen
Corporate Officer · Individual
Magyar, Cheryl
Operational/Managerial Control · Individual
Magyar, Cheryl
Corporate Director · Individual
Magyar, Cheryl
Corporate Officer · Individual
Magyar, Cheryl
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Nazareth Home
Louisville, KY
5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
#2
Eastway Health & Rehabilitation
Louisville, KY
2-star overall rating with 1-star inspections with $13,762 in total fines with 2 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Highlands Nursing and Rehabilitation
Louisville, KY
2-star overall rating with 2-star inspections with $17,523 in total fines with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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