Cycle 1
Health 2025-05-08 · Fire 2025-05-08
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
8 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Louisville, KY
Nazareth Home Clifton
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
2120 Payne Street, Louisville, KY
(502) 895-9425
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
113
Certified beds
Average residents
106
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2000-01-28
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
0.70
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.20
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.56
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
4.45
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.90
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.03
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.54
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
0.69
CMS adjusted RN staffing hours
Adjusted total hours
4.39
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
24%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,253
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
58.36
Composite VBP score used to determine payment impact.
Payment multiplier
1.0136
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.63
Baseline 20.84% · Performance 17.43% · Measure score 8.63 · Achievement 8.63 · Improvement 8.45
Healthcare-associated infections
8.16
Baseline 5.80% · Performance 5.39% · Measure score 8.16 · Achievement 8.16 · Improvement 4.57
Total nurse turnover
2.15
Baseline 49.12% · Performance 54.89% · Measure score 2.15 · Achievement 2.15 · Improvement 0
Adjusted total nurse staffing
4.39
Baseline 4.45 hours · Performance 4.33 hours · Measure score 4.39 · Achievement 4.39 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.29% |
10.72%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 423 · Observed rate 11.58% · Lower 95% interval 9.85% |
| Discharge to community | 67.83% |
50.57%
17.3 pts better
|
Better than the National Rate · Eligible stays 412 · Observed rate 66.99% · Lower 95% interval 62.62% |
| Medicare spending per beneficiary | 0.76 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 99.49% |
95.27%
4.2 pts better
|
Numerator 194 · Denominator 195 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 195 |
| Discharge self-care score | 52.98% |
53.69%
0.7 pts worse
|
Numerator 89 · Denominator 168 |
| Discharge mobility score | 51.19% |
50.94%
0.2 pts better
|
Numerator 86 · Denominator 168 |
| Pressure ulcers or injuries, new or worsened | 1.03% |
2.29%
1.3 pts better
|
Numerator 2 · Denominator 195 · Adjusted rate 1.32% |
| Healthcare-associated infections requiring hospitalization | 5.39% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 226 · Observed rate 3.1% · Lower 95% interval 3.34% |
| Staff COVID-19 vaccination coverage | 3.68% |
8.2%
4.5 pts worse
|
Numerator 7 · Denominator 190 |
| Staff flu vaccination coverage | 87.56% |
42%
45.6 pts better
|
Numerator 190 · Denominator 217 |
| Discharge function score | 49.4% |
56.45%
7.1 pts worse
|
Numerator 83 · Denominator 168 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 26 · Denominator 26 |
| Transfer of health information to patient | 98.53% |
96.28%
2.2 pts better
|
Numerator 134 · Denominator 136 |
| Resident COVID-19 vaccinations up to date | 36.78% |
25.2%
11.6 pts better
|
Numerator 32 · Denominator 87 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.9
0.8 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.2 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
2.2
2 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.2 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.9% |
94.3%
0.4 pts worse
|
93.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 85.1% · Q2 94.2% · Q3 96.4% · Q4 98.8% · 4Q avg 93.9% |
| 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 | 3.1% |
3.8%
0.7 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 4.7% · Q3 3.6% · Q4 2.4% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
15.2%
13.2 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.8% · Q3 2.5% · Q4 1.3% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 6.6% |
6.7%
0.1 pts better
|
5.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 4.0% · Q3 10.7% · Q4 2.7% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.6% |
29.6%
2 pts better
|
19.6%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 24.7% · Q3 29.3% · Q4 29.3% · 4Q avg 27.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.6% |
17.6%
13 pts better
|
16.7%
12.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.8% · Q3 4.8% · Q4 4.8% · 4Q avg 4.6% · 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 | 21.0% |
17.3%
3.7 pts worse
|
16.3%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.2% · Q2 28.5% · Q3 20.7% · Q4 20.6% · 4Q avg 21.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.7% |
15.6%
1.9 pts better
|
14.9%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 18.2% · Q3 15.3% · Q4 11.1% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.7%
About the same
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.8% · Q3 0.9% · Q4 1.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
1.7%
0.1 pts worse
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 1.2% · Q3 0.0% · Q4 2.4% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.5% |
19.8%
1.7 pts worse
|
19.8%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.0% · Q2 22.0% · Q3 20.1% · Q4 17.6% · 4Q avg 21.5% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
5.5%
0.1 pts better
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 3.4% · Q3 4.2% · Q4 6.6% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.7% |
83.8%
10.9 pts better
|
81.7%
13 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.3% · Q2 97.1% · Q3 96.7% · Q4 97.2% · 4Q avg 94.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.0% |
13.9%
9.9 pts better
|
12.0%
8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.0% · Observed 3.4% · Expected 9.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.8%
1.6 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.5% |
83.6%
11.9 pts better
|
79.7%
15.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| 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 13.4% · Expected 19.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-01-16 · Fire 2020-01-16
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2018-11-21 · Fire 2018-11-21
16 health deficiencies
Top issue: Resident Rights (4 deficiencies)
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
2025-05-08
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-05-24
F · Potential for more than minimal harm
2025-05-08
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-05-24
F · Potential for more than minimal harm
2025-05-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-19
F · Potential for more than minimal harm
2025-05-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-08
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 2025-05-28
D · Potential for more than minimal harm
2025-05-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-06-01
D · Potential for more than minimal harm
2025-05-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-08
D · Potential for more than minimal harm
2025-05-08
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-06-13
F · Potential for more than minimal harm
2020-01-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-02-11
F · Potential for more than minimal harm
2020-01-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-02-18
D · Potential for more than minimal harm
2020-01-16
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2020-02-11
D · Potential for more than minimal harm
2020-01-16
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2020-01-29
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-08
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 2025-05-24
D · Potential for more than minimal harm
2023-11-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-11-22
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-11-22
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-11-22
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 2024-02-02
D · Potential for more than minimal harm
2023-11-22
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 2024-02-02
D · Potential for more than minimal harm
2023-11-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-02-02
D · Potential for more than minimal harm
2023-11-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-02
F · Potential for more than minimal harm
2018-11-21
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 2018-12-29
D · Potential for more than minimal harm
2018-11-21
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2018-12-29
D · Potential for more than minimal harm
2018-11-21
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2018-12-29
D · Potential for more than minimal harm
2018-11-21
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2018-12-29
D · Potential for more than minimal harm
2018-11-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-12-13
D · Potential for more than minimal harm
2018-11-21
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 2018-12-13
D · Potential for more than minimal harm
2018-11-21
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 2018-12-29
D · Potential for more than minimal harm
2018-11-21
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 2018-12-29
D · Potential for more than minimal harm
2018-11-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-12-27
Penalties and ownership
What sits behind the stars
Ownership
Askin, Sarah
Operational/Managerial Control · Individual
Bricker, Paul
Operational/Managerial Control · Individual
Brosky, Joseph
Corporate Director · Individual
Cobb, Greg
Corporate Director · Individual
Cochran, Ashley
Operational/Managerial Control · Individual
Elder, Erin
Operational/Managerial Control · Individual
Fegenbush, Carolyn
Corporate Director · Individual
Hammer, William
Corporate Director · Individual
Haynes, Mary
Operational/Managerial Control · Individual
Haynes, Mary
Corporate Officer · Individual
Hobson, Kimberly
Operational/Managerial Control · Individual
Lucchese, John
Corporate Director · Individual
Miles, Rebecca
Corporate Director · Individual
Passafiume, Clara
Corporate Director · Individual
Smith, Jason
Corporate Director · Individual
Thomas Kuerzi, Jennifer
Corporate Director · Individual
Williams, Amy
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
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
#2
Clifton Heights
Louisville, KY
1-star overall rating with 1-star inspections with Special Focus status with $369,780 in total fines with 18 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Home of the Innocents
Louisville, KY
2-star overall rating with 1-star inspections with 8 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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