Cycle 1
Health 2024-08-01 · Fire 2024-08-01
3 health deficiencies
Top issue: Infection Control (2 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Shelbyville, KY
Maple Grove Senior Living LLC
3-star overall rating with 3-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
711 Frankfort Road, Shelbyville, KY
(502) 633-3486
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
117
Certified beds
Average residents
76
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Ecc Trust
Operator or chain grouping
Approved since
1993-04-28
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
4 facilities
Chain averages 4 overall / 4 health / 4 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
0.60
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.00
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.59
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
4.19
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.77
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.20
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
0.60
CMS adjusted RN staffing hours
Adjusted total hours
4.19
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
10%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,691
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.94
Composite VBP score used to determine payment impact.
Payment multiplier
0.9920
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.32
Baseline 21.22% · Performance 20.82% · Measure score 1.32 · Achievement 1.32 · Improvement 0.46
Healthcare-associated infections
3.97
Baseline 5.77% · Performance 6.65% · Measure score 3.97 · Achievement 3.97 · Improvement 0
Total nurse turnover
4.46
Baseline 51.85% · Performance 45.45% · Measure score 4.46 · Achievement 4.46 · Improvement 1.87
Adjusted total nurse staffing
5.82
Baseline 3.86 hours · Performance 4.73 hours · Measure score 5.82 · Achievement 5.82 · Improvement 4.05
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.07% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 161 · Observed rate 8.07% · Lower 95% interval 7.12% |
| Discharge to community | 56.48% |
50.57%
5.9 pts better
|
No Different than the National Rate · Eligible stays 162 · Observed rate 54.32% · Lower 95% interval 49.23% |
| Medicare spending per beneficiary | 0.75 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 88 · Denominator 88 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 88 |
| Discharge self-care score | 54.93% |
53.69%
1.2 pts better
|
Numerator 39 · Denominator 71 |
| Discharge mobility score | 32.39% |
50.94%
18.5 pts worse
|
Numerator 23 · Denominator 71 |
| Pressure ulcers or injuries, new or worsened | 2.27% |
2.29%
About the same
|
Numerator 2 · Denominator 88 · Adjusted rate 1.99% |
| Healthcare-associated infections requiring hospitalization | 6.65% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 96 · Observed rate 5.21% · Lower 95% interval 4.01% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 168 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 50.7% |
56.45%
5.8 pts worse
|
Numerator 36 · Denominator 71 |
| 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 | 100% |
96.28%
3.7 pts better
|
Numerator 52 · Denominator 52 |
| Resident COVID-19 vaccinations up to date | 35.71% |
25.2%
10.5 pts better
|
Numerator 15 · Denominator 42 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.9
0.2 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.7 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
2.2
0.5 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
94.3%
5 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.1% · Q4 100.0% · 4Q avg 99.3% |
| 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 | 5.8% |
3.8%
2 pts worse
|
3.3%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 8.5% · Q3 5.7% · Q4 2.9% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
15.2%
14.8 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 5.5% |
6.7%
1.2 pts better
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 1.7% · Q3 5.4% · Q4 7.0% · 4Q avg 5.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.2% |
29.6%
8.4 pts better
|
19.6%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 19.7% · Q3 22.4% · Q4 26.3% · 4Q avg 21.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.0% |
17.6%
11.6 pts better
|
16.7%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 6.7% · Q3 3.4% · Q4 5.5% · 4Q avg 6.0% · 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 | 25.2% |
17.3%
7.9 pts worse
|
16.3%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.9% · Q2 35.0% · Q4 19.0% · 4Q avg 25.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.9% |
15.6%
0.3 pts worse
|
14.9%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 14.5% · Q3 17.3% · Q4 14.0% · 4Q avg 15.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.7%
0.1 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
1.7%
0.9 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.4% · Q3 0.0% · Q4 7.1% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.1% |
19.8%
6.3 pts worse
|
19.8%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.1% · Q2 23.2% · Q3 21.6% · Q4 29.5% · 4Q avg 26.1% |
| 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 3.1% · Q2 1.4% · Q3 4.1% · Q4 3.5% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
83.8%
13.4 pts better
|
81.7%
15.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.7% · Q3 94.1% · Q4 97.5% · 4Q avg 97.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.9% |
13.9%
1 pts better
|
12.0%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.9% · Observed 11.5% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.8%
0.3 pts better
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.4% |
83.6%
6.8 pts better
|
79.7%
10.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.1% |
24.5%
8.4 pts better
|
23.9%
7.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.1% · Observed 14.1% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-04-12 · Fire 2019-04-12
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2018-01-25 · Fire 2018-01-25
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
2024-08-01
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-09-13
F · Potential for more than minimal harm
2024-08-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-13
F · Potential for more than minimal harm
2024-08-01
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-09-13
E · Potential for more than minimal harm
2024-08-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-13
E · Potential for more than minimal harm
2024-08-01
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 2024-09-13
D · Potential for more than minimal harm
2024-08-01
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 2024-09-13
D · Potential for more than minimal harm
2024-08-01
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2024-09-13
D · Potential for more than minimal harm
2019-04-12
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2019-05-14
D · Potential for more than minimal harm
2019-04-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-05-14
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-08-01
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 2024-09-13
E · Potential for more than minimal harm
2024-08-01
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-09-13
D · Potential for more than minimal harm
2024-08-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-13
D · Potential for more than minimal harm
2019-04-12
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 2019-05-14
Penalties and ownership
What sits behind the stars
Ownership
Ecc Trust
5% Or Greater Direct Ownership Interest · Organization
Brown, Ervin
5% Or Greater Indirect Ownership Interest · Individual
Cox, Douglas
Operational/Managerial Control · Individual
Cox, Douglas
Corporate Officer · Individual
Cox, Gretchen
5% Or Greater Indirect Ownership Interest · Individual
Cunningham, Janie
Operational/Managerial Control · Individual
Mitchell, Gregory
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Crestview Healthcare and Rehabilitation
Shelbyville, KY
5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
#2
Signature Healthcare of Spencer County
Taylorsville, KY
2-star overall rating with 2-star inspections with 7 recent health deficiencies
#3
New Castle Nursing & Rehab
New Castle, KY
5-star overall rating with 5-star inspections with 7 fire-safety deficiencies in the latest cycle
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