Cycle 1
Health 2022-10-22 · Fire 2022-10-22
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Edmonton, KY
Metcalfe Health Care Center
2-star overall rating with 2-star inspections with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
701 Skyline Drive, Edmonton, KY
(270) 432-2921
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
71
Certified beds
Average residents
62
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-11-01
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
0.54
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.94
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
4.40
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.47
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.69
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
4.57
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,211
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.90
Composite VBP score used to determine payment impact.
Payment multiplier
0.9938
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.48
Performance 17.96% · Measure score 7.48 · Achievement 7.48 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Baseline 5.68% · Performance 7.86% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.55
Baseline 39.34% · Performance 45.07% · Measure score 4.55 · Achievement 4.55 · Improvement 0
Adjusted total nurse staffing
4.32
Baseline 3.69 hours · Performance 4.31 hours · Measure score 4.32 · Achievement 4.32 · Improvement 2.45
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.51% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 58 · Observed rate 13.79% · Lower 95% interval 7.41% |
| Discharge to community | 47.28% |
50.57%
3.3 pts worse
|
No Different than the National Rate · Eligible stays 41 · Observed rate 43.9% · Lower 95% interval 38.1% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 93.94% |
95.27%
1.3 pts worse
|
Numerator 31 · Denominator 33 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 33 |
| Discharge self-care score | 47.83% |
53.69%
5.9 pts worse
|
Numerator 11 · Denominator 23 |
| Discharge mobility score | 34.78% |
50.94%
16.2 pts worse
|
Numerator 8 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 12.12% |
2.29%
9.8 pts worse
|
Numerator 4 · Denominator 33 · Adjusted rate 12.32% |
| Healthcare-associated infections requiring hospitalization | 7.86% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 30 · Observed rate 10% · Lower 95% interval 4.16% |
| Staff COVID-19 vaccination coverage | 1.01% |
8.2%
7.2 pts worse
|
Numerator 1 · Denominator 99 |
| Staff flu vaccination coverage | 17.27% |
42%
24.7 pts worse
|
Numerator 19 · Denominator 110 |
| Discharge function score | 43.48% |
56.45%
13 pts worse
|
Numerator 10 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · 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 | 2.1 |
1.9
0.2 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 1.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
2.2
0.6 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.8 · Observed 2.5 · Expected 1.5 · 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 | 8.3% |
3.8%
4.5 pts worse
|
3.3%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 9.8% · Q3 7.8% · Q4 2.0% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.6% |
15.2%
13.6 pts better
|
11.4%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.3% · Q4 2.0% · 4Q avg 1.6% |
| Percentage of long-stay residents who lose too much weight | 5.7% |
6.7%
1 pts better
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 6.2% · Q3 0.0% · Q4 2.0% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 34.7% |
29.6%
5.1 pts worse
|
19.6%
15.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.7% · Q2 34.7% · Q3 35.4% · Q4 36.0% · 4Q avg 34.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 36.6% |
17.6%
19 pts worse
|
16.7%
19.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.9% · Q2 36.4% · Q3 35.0% · Q4 33.3% · 4Q avg 36.6% · 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 | 19.9% |
17.3%
2.6 pts worse
|
16.3%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q4 22.6% · 4Q avg 19.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.6% |
15.6%
5 pts better
|
14.9%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 15.6% · Q3 2.4% · Q4 10.6% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 5.6% |
0.7%
4.9 pts worse
|
1.0%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 9.2% · Q3 3.0% · Q4 3.1% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.9% |
1.7%
5.2 pts worse
|
1.7%
5.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 2.0% · Q3 8.2% · Q4 11.8% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.9% |
19.8%
1.1 pts worse
|
19.8%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.9% · Q2 20.3% · Q3 19.4% · Q4 23.8% · 4Q avg 20.9% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
5.5%
1.9 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 5.3% · Q3 3.0% · Q4 1.5% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
83.8%
14.4 pts better
|
81.7%
16.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.8% · Q4 95.7% · 4Q avg 98.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.7% |
13.9%
4.8 pts worse
|
12.0%
6.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.7% · Observed 17.4% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.8%
1.8 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.2% |
83.6%
6.6 pts better
|
79.7%
10.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.4% |
24.5%
8.1 pts better
|
23.9%
7.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.4% · Observed 17.4% · Expected 25.3% · Used in QM five-star |
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)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2018-10-25 · Fire 2018-10-25
3 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
2022-10-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-26
F · Potential for more than minimal harm
2022-10-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-26
E · Potential for more than minimal harm
2022-10-22
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 2023-01-26
E · Potential for more than minimal harm
2022-10-22
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 2023-01-26
E · Potential for more than minimal harm
2022-10-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-01-26
Inspection history
Recent health citations
F · Potential for more than minimal harm
2022-10-22
F576 · Resident Rights Deficiencies
Health
Ensure residents have reasonable access to and privacy in their use of communication methods.
Corrected 2023-02-22
F · Potential for more than minimal harm
2022-10-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-22
E · Potential for more than minimal harm
2022-10-22
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-02-22
E · Potential for more than minimal harm
2022-10-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-02-22
E · Potential for more than minimal harm
2022-10-22
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 2023-02-22
D · Potential for more than minimal harm
2022-10-22
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-02-22
D · Potential for more than minimal harm
2022-10-22
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-02-22
D · Potential for more than minimal harm
2022-10-22
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 2023-02-22
D · Potential for more than minimal harm
2022-10-22
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 2023-02-22
D · Potential for more than minimal harm
2022-10-22
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-02-22
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 2019-11-07
F · Potential for more than minimal harm
2018-10-25
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2018-11-16
E · Potential for more than minimal harm
2018-10-25
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2018-11-16
D · Potential for more than minimal harm
2018-10-25
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2018-11-16
Penalties and ownership
What sits behind the stars
Ownership
Britt, Courtney
Operational/Managerial Control · Individual
Brooks, Cody
Operational/Managerial Control · Individual
Hope, Kaye
Operational/Managerial Control · Individual
Hope, Kaye
Corporate Director · Individual
Howard, Sharon
Operational/Managerial Control · Individual
Howard, Sharon
Corporate Officer · Individual
Lehman, Janine
Operational/Managerial Control · Individual
Lile, Benny
Operational/Managerial Control · Individual
Lile, Benny
Corporate Director · Individual
Parker, Jackie
Operational/Managerial Control · Individual
Parker, Jackie
Corporate Director · Individual
Skaggs, Terry
Operational/Managerial Control · Individual
Steele, Nancy
Operational/Managerial Control · Individual
Steele, Nancy
Corporate Director · Individual
Wells Health Services, Inc.
Operational/Managerial Control · Organization
Wells, Gregory
Operational/Managerial Control · Individual
Wilson, Larry
Operational/Managerial Control · Individual
Wilson, Larry
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Glenview Health and Rehabilitation
Glasgow, KY
1-star overall rating with 3-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
NHC Healthcare, Glasgow
Glasgow, KY
3-star overall rating with 3-star inspections with $4,017 in total fines with 2 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Glasgow State Nursing Facility
Glasgow, KY
3-star overall rating with 2-star inspections with $62,189 in total fines with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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