Cycle 1
Health 2024-08-02 · Fire 2024-08-02
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
11 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Louisvile, KY
Regency Nursing and Rehabilitation Center
1-star overall rating with 1-star inspections with $10,039 in total fines with 4 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
1550 Raydale Drive, Louisvile, KY
(502) 968-6600
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
106
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Encore Health Partners
Operator or chain grouping
Approved since
1991-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
12 facilities
Chain averages 3 overall / 3 health / 2 staffing / 3 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
1.04
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.43
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.50
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
3.26
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.99
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.90
CMS adjusted RN staffing hours
Adjusted total hours
3.04
CMS adjusted total nurse staffing hours
Case-mix index
1.57
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,558
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
3.74
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.45% · Performance 21.70% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.52% · Performance 10.35% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0.18
Baseline 69.16% · Performance 66.15% · Measure score 0.18 · Achievement 0 · Improvement 0.18
Adjusted total nurse staffing
1.32
Baseline 3.49 hours · Performance 3.45 hours · Measure score 1.32 · Achievement 1.32 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.35% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 18% · Lower 95% interval 7.84% |
| Discharge to community | 40.19% |
50.57%
10.4 pts worse
|
No Different than the National Rate · Eligible stays 39 · Observed rate 23.08% · Lower 95% interval 25.43% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 40 · Denominator 40 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 40 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 2.5% |
2.29%
0.2 pts worse
|
Numerator 1 · Denominator 40 · Adjusted rate 1.74% |
| Healthcare-associated infections requiring hospitalization | 10.35% |
7.12%
3.2 pts worse
|
No Different than the National Rate · Eligible stays 48 · Observed rate 25% · Lower 95% interval 6.36% |
| Staff COVID-19 vaccination coverage | 0.72% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 139 |
| Staff flu vaccination coverage | 22.58% |
42%
19.4 pts worse
|
Numerator 35 · Denominator 155 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | 96% |
95.95%
About the same
|
Numerator 24 · Denominator 25 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 5% |
25.2%
20.2 pts worse
|
Numerator 1 · Denominator 20 |
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 2.8 · Expected 2.6 · 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 1.0 · Expected 1.8 · 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 | 97.1% |
96.2%
0.9 pts better
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
3.8%
2.8 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 1.0% · Q4 1.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 27.3% |
15.2%
12.1 pts worse
|
11.4%
15.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 29.6% · Q3 33.0% · Q4 32.6% · 4Q avg 27.3% |
| Percentage of long-stay residents who lose too much weight | 5.4% |
6.7%
1.3 pts better
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 5.6% · Q3 5.4% · Q4 6.0% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.1% |
29.6%
5.5 pts better
|
19.6%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.7% · Q2 21.7% · Q3 22.9% · Q4 27.0% · 4Q avg 24.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.4% |
17.6%
3.2 pts better
|
16.7%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 15.3% · Q3 17.1% · Q4 11.5% · 4Q avg 14.4% · 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 | 14.9% |
17.3%
2.4 pts better
|
16.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 42.6% · Q2 8.3% · Q3 9.3% · Q4 5.8% · 4Q avg 14.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.7% |
15.6%
2.1 pts worse
|
14.9%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.0% · Q2 16.1% · Q3 14.6% · Q4 7.4% · 4Q avg 17.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.7%
0.2 pts worse
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.7%
1.2 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.2% |
19.8%
3.4 pts worse
|
19.8%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.0% · Q2 20.9% · Q3 24.0% · Q4 17.1% · 4Q avg 23.2% |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
5.5%
1 pts worse
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 5.7% · Q3 5.9% · Q4 6.0% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
83.8%
14.1 pts better
|
81.7%
16.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.0% · Q3 97.1% · Q4 100.0% · 4Q avg 97.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.6% |
13.9%
8.3 pts better
|
12.0%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.6% · Observed 7.0% · Expected 14.0% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.5% |
83.6%
4.1 pts worse
|
79.7%
0.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.4% |
24.5%
3.9 pts worse
|
23.9%
4.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.4% · Observed 44.2% · Expected 37.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-08-23 · Fire 2019-08-23
16 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2018-05-24 · Fire 2018-05-24
6 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-08-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-08-02
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-08-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-08-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-29
F · Potential for more than minimal harm
2024-08-02
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-08-29
E · Potential for more than minimal harm
2024-08-02
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-08-29
E · Potential for more than minimal harm
2024-08-02
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-08-29
E · Potential for more than minimal harm
2024-08-02
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-08-29
E · Potential for more than minimal harm
2024-08-02
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 2024-08-29
E · Potential for more than minimal harm
2024-08-02
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-29
D · Potential for more than minimal harm
2019-08-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-12-16
F · Potential for more than minimal harm
2018-05-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-06-19
E · Potential for more than minimal harm
2018-05-24
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2018-06-19
Inspection history
Recent health citations
J · Immediate jeopardy
2024-08-02
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 2023-01-30
J · Immediate jeopardy
2024-08-02
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 2023-01-30
F · Potential for more than minimal harm
2024-08-02
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 2024-08-28
E · Potential for more than minimal harm
2024-08-02
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-08-28
J · Immediate jeopardy
2019-08-23
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2020-01-02
J · Immediate jeopardy
2019-08-23
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 2019-10-16
J · Immediate jeopardy
2019-08-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2019-10-16
J · Immediate jeopardy
2019-08-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-10-16
J · Immediate jeopardy
2019-08-23
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 2020-01-02
J · Immediate jeopardy
2019-08-23
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 2020-01-02
J · Immediate jeopardy
2019-08-23
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2020-01-02
J · Immediate jeopardy
2019-08-23
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-01-02
J · Immediate jeopardy
2019-08-23
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2020-01-02
J · Immediate jeopardy
2019-08-23
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2020-01-02
G · Actual harm
2019-08-23
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 2019-10-16
G · Actual harm
2019-08-23
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-10-16
E · Potential for more than minimal harm
2019-08-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-10-16
D · Potential for more than minimal harm
2019-08-23
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2019-10-16
D · Potential for more than minimal harm
2019-08-23
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2019-10-16
D · Potential for more than minimal harm
2019-08-23
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2019-10-16
F · Potential for more than minimal harm
2018-05-24
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2018-06-19
F · Potential for more than minimal harm
2018-05-24
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 2018-06-19
E · Potential for more than minimal harm
2018-05-24
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 2018-06-19
D · Potential for more than minimal harm
2018-05-24
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 2018-06-19
D · Potential for more than minimal harm
2018-05-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-06-19
D · Potential for more than minimal harm
2018-05-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-06-19
Penalties and ownership
What sits behind the stars
$10,039
2024-08-02
Fine
Fine · fine $10,039
Fine
Ownership
Encore Parent Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
1550 Raydale Drive Realty
5% Or Greater Mortgage Interest · Organization
Bloom, David
5% Or Greater Indirect Ownership Interest · Individual
Dwight Mortgage Trust LLC
5% Or Greater Mortgage Interest · Organization
Encore Health Partners 2 LLC
Operational/Managerial Control · Organization
Encore Investors 2 LLC
5% Or Greater Indirect Ownership Interest · Organization
Fischl, Mayer
Operational/Managerial Control · Individual
Fischl, Mayer
Corporate Officer · Individual
Grinspan, Eli
5% Or Greater Indirect Ownership Interest · Individual
Grinspan, Eli
Operational/Managerial Control · Individual
Grinspan, Eli
Corporate Officer · Individual
Grinspan, Isaac
5% Or Greater Indirect Ownership Interest · Individual
Mono, Annabel
Operational/Managerial Control · Individual
Rubenstein, David
5% Or Greater Indirect Ownership Interest · Individual
Zoberman, Sarah
5% Or Greater Indirect Ownership Interest · Individual
Nearby options
Other facilities in reach
#1
Wesley Manor
Louisville, KY
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Franciscan Health Care Center
Louisville, KY
3-star overall rating with 2-star inspections with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Klondike Nursing and Rehabilitation Center
Louisville, KY
3-star overall rating with 2-star inspections with $33,062 in total fines with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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