Cycle 1
Health 2025-07-09 · Fire 2025-07-09
6 health deficiencies
Top issue: Resident Rights (3 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Louisville, KY
River Oaks Health & Rehabilitation
1-star overall rating with 2-star inspections with 6 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
920 South 4th Street, Louisville, KY
(502) 583-6533
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
122
Certified beds
Average residents
104
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Christian Care Communities
Operator or chain grouping
Approved since
1967-01-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 3 overall / 3 health / 3 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
0.48
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.51
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.25
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.40
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
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.63
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
4,243
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.72
Composite VBP score used to determine payment impact.
Payment multiplier
0.9936
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.50
Baseline 19.36% · Performance 18.42% · Measure score 6.50 · Achievement 6.50 · Improvement 3.54
Healthcare-associated infections
5.71
Baseline 5.83% · Performance 6.13% · Measure score 5.71 · Achievement 5.71 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0
Baseline 4.4 hours · Performance 3.22 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.86% |
10.72%
1.9 pts better
|
No Different than the National Rate · Eligible stays 64 · Observed rate 3.13% · Lower 95% interval 5.83% |
| Discharge to community | 61.58% |
50.57%
11 pts better
|
No Different than the National Rate · Eligible stays 49 · Observed rate 55.1% · Lower 95% interval 47.31% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.78% |
95.27%
2.5 pts better
|
Numerator 44 · Denominator 45 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 45 |
| Discharge self-care score | 48.39% |
53.69%
5.3 pts worse
|
Numerator 15 · Denominator 31 |
| Discharge mobility score | 48.39% |
50.94%
2.5 pts worse
|
Numerator 15 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 6.67% |
2.29%
4.4 pts worse
|
Numerator 3 · Denominator 45 · Adjusted rate 4.85% |
| Healthcare-associated infections requiring hospitalization | 6.13% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 27 · Observed rate 0% · Lower 95% interval 2.83% |
| Staff COVID-19 vaccination coverage | 17.36% |
8.2%
9.2 pts better
|
Numerator 25 · Denominator 144 |
| Staff flu vaccination coverage | 72.54% |
42%
30.5 pts better
|
Numerator 103 · Denominator 142 |
| Discharge function score | 51.61% |
56.45%
4.8 pts worse
|
Numerator 16 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 67.86% |
25.2%
42.7 pts better
|
Numerator 19 · Denominator 28 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.9
About the same
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.0 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.2
0.8 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.4 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.1% |
94.3%
0.8 pts better
|
93.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.9% · Q3 94.4% · Q4 88.3% · 4Q avg 95.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.7% |
96.2%
0.5 pts worse
|
95.5%
0.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| 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 3.8% · Q2 4.5% · Q3 3.3% · Q4 1.1% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
15.2%
14.9 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 8.4% |
6.7%
1.7 pts worse
|
5.4%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 10.5% · Q3 4.5% · Q4 7.9% · 4Q avg 8.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.5% |
29.6%
0.9 pts worse
|
19.6%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.5% · Q2 30.7% · Q3 31.1% · Q4 28.0% · 4Q avg 30.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.6% |
17.6%
1 pts worse
|
16.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 20.0% · Q3 20.9% · Q4 16.9% · 4Q avg 18.6% · 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 | 14.5% |
17.3%
2.8 pts better
|
16.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 28.9% · Q2 12.7% · Q3 0.0% · Q4 18.1% · 4Q avg 14.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.8% |
15.6%
3.8 pts better
|
14.9%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 10.1% · Q3 7.8% · Q4 19.5% · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.9% |
0.7%
2.2 pts worse
|
1.0%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 3.3% · Q3 2.6% · Q4 2.5% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.7%
0.5 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 1.2% · Q3 1.1% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.7% |
19.8%
0.1 pts better
|
19.8%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 26.0% · Q3 20.4% · Q4 20.6% · 4Q avg 19.7% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
5.5%
2.3 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 4.3% · Q3 2.0% · Q4 3.2% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 64.8% |
83.8%
19 pts worse
|
81.7%
16.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 70.1% · Q2 66.0% · Q3 68.2% · Q4 53.5% · 4Q avg 64.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.3% |
13.9%
0.6 pts better
|
12.0%
1.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.3% · Observed 13.6% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.1% |
1.8%
1.3 pts worse
|
1.6%
1.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 3.8% · Q3 2.0% · Q4 0.0% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.7% |
83.6%
9.9 pts worse
|
79.7%
6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 73.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.6% |
24.5%
0.9 pts better
|
23.9%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.6% · Observed 25.0% · Expected 25.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-07 · Fire 2024-06-07
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
14 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Cycle 3
Health 2019-03-15 · Fire 2019-03-15
4 health deficiencies
Top issue: Infection Control (2 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
2025-07-09
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2025-08-15
F · Potential for more than minimal harm
2025-07-09
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-08-15
F · Potential for more than minimal harm
2025-07-09
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-08-15
F · Potential for more than minimal harm
2025-07-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-19
F · Potential for more than minimal harm
2025-07-09
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 2025-08-15
F · Potential for more than minimal harm
2025-07-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-15
E · Potential for more than minimal harm
2025-07-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-07-09
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 2025-08-15
D · Potential for more than minimal harm
2025-07-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-08-15
D · Potential for more than minimal harm
2025-07-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-08-15
F · Potential for more than minimal harm
2024-06-07
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2024-07-04
F · Potential for more than minimal harm
2024-06-07
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-07-04
F · Potential for more than minimal harm
2024-06-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-07-04
F · Potential for more than minimal harm
2024-06-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-04
F · Potential for more than minimal harm
2024-06-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-06-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-04
F · Potential for more than minimal harm
2024-06-07
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 2024-07-04
F · Potential for more than minimal harm
2024-06-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-06
F · Potential for more than minimal harm
2024-06-07
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-07-04
E · Potential for more than minimal harm
2024-06-07
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-07-04
E · Potential for more than minimal harm
2024-06-07
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-07-04
E · Potential for more than minimal harm
2024-06-07
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-06-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-07-04
D · Potential for more than minimal harm
2024-06-07
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 2024-07-04
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-09
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 2025-08-08
D · Potential for more than minimal harm
2025-07-09
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-07-09
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-08-08
D · Potential for more than minimal harm
2025-07-09
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 2025-08-08
D · Potential for more than minimal harm
2025-07-09
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 2025-08-08
D · Potential for more than minimal harm
2025-07-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-08
C · Minimal harm
2024-11-22
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-10-18
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 2024-11-11
E · Potential for more than minimal harm
2024-10-18
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 2024-11-11
E · Potential for more than minimal harm
2024-06-07
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 2024-07-04
E · Potential for more than minimal harm
2024-06-07
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 2024-07-04
E · Potential for more than minimal harm
2024-06-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-04
F · Potential for more than minimal harm
2019-03-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-05-08
F · Potential for more than minimal harm
2019-03-15
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2019-05-08
E · Potential for more than minimal harm
2019-03-15
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2019-05-08
D · Potential for more than minimal harm
2019-03-15
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2019-05-08
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
Treyton Oak Towers
Louisville, KY
2-star overall rating with 1-star inspections with $16,724 in total fines with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Chestnut Ridge Health & Rehabilitation
Louisville, KY
1-star overall rating with 1-star inspections with Special Focus status with $306,141 in total fines with 23 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#3
Kindred Hospital - Louisville
Louisville, KY
2-star overall rating with 2-star inspections with $64,799 in total fines with 3 recent health deficiencies
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