Cycle 1
Health 2025-08-21 · Fire 2025-08-21
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Bardstown, KY
Signature Healthcare At Colonial Rehab & Wellness
1-star overall rating with 1-star inspections with $67,987 in total fines with 3 fire-safety deficiencies in the latest cycle
708 Bartley Avenue, Bardstown, KY
(502) 348-9260
Overall
1 / 5
CMS overall stars
Health inspections
1 / 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
65
Certified beds
Average residents
54
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Signature Healthcare
Operator or chain grouping
Approved since
1992-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
71 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
1.16
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.30
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.34
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.80
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.07
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.69
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.17
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.11
CMS adjusted RN staffing hours
Adjusted total hours
3.62
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,692
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.24
Composite VBP score used to determine payment impact.
Payment multiplier
1.0019
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.71
Baseline 21.53% · Performance 19.71% · Measure score 3.71 · Achievement 3.71 · Improvement 3.54
Healthcare-associated infections
6.14
Baseline 6.50% · Performance 6.00% · Measure score 6.14 · Achievement 6.14 · Improvement 2.84
Total nurse turnover
7.97
Baseline 58.06% · Performance 31.11% · Measure score 7.97 · Achievement 7.97 · Improvement 7.62
Adjusted total nurse staffing
1.48
Baseline 3.68 hours · Performance 3.50 hours · Measure score 1.48 · Achievement 1.48 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.86% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 67 · Observed rate 11.94% · Lower 95% interval 7.87% |
| Discharge to community | 48.31% |
50.57%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 68 · Observed rate 41.18% · Lower 95% interval 37.1% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 33 · Denominator 33 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 33 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 3.03% |
2.29%
0.7 pts worse
|
Numerator 1 · Denominator 33 · Adjusted rate 3.08% |
| Healthcare-associated infections requiring hospitalization | 6% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 2.33% · Lower 95% interval 2.84% |
| Staff COVID-19 vaccination coverage | 3.33% |
8.2%
4.9 pts worse
|
Numerator 2 · Denominator 60 |
| Staff flu vaccination coverage | 24.39% |
42%
17.6 pts worse
|
Numerator 20 · Denominator 82 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 24% |
25.2%
1.2 pts worse
|
Numerator 6 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
94.3%
5.1 pts better
|
93.4%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.6% · Q3 100.0% · Q4 100.0% · 4Q avg 99.4% |
| 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 | 6.3% |
3.8%
2.5 pts worse
|
3.3%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 7.1% · Q3 7.1% · Q4 4.4% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 25.2% |
15.2%
10 pts worse
|
11.4%
13.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.7% · Q2 25.0% · Q3 30.8% · Q4 15.4% · 4Q avg 25.2% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
6.7%
2 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 5.0% · Q3 0.0% · Q4 6.7% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 33.9% |
29.6%
4.3 pts worse
|
19.6%
14.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.6% · Q2 31.0% · Q3 35.7% · Q4 33.3% · 4Q avg 33.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.8% |
17.6%
8.8 pts better
|
16.7%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 12.1% · Q3 5.4% · Q4 8.1% · 4Q avg 8.8% · 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 | 3.9% |
17.3%
13.4 pts better
|
16.3%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q4 0.0% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.1% |
15.6%
3.5 pts better
|
14.9%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 10.5% · Q3 10.3% · Q4 2.4% · 4Q avg 12.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.7%
1.1 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.3% |
19.8%
3.5 pts better
|
19.8%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 24.9% · Q3 18.6% · Q4 11.4% · 4Q avg 16.3% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
5.5%
1.7 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 0.0% · Q3 3.1% · Q4 4.9% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.9% |
83.8%
5.1 pts better
|
81.7%
7.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 81.8% · Q2 83.3% · Q3 90.6% · Q4 100.0% · 4Q avg 88.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.4% |
13.9%
0.5 pts better
|
12.0%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.4% · Observed 14.9% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.8%
0.9 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.1% |
83.6%
3.5 pts better
|
79.7%
7.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.9% |
24.5%
3.6 pts better
|
23.9%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.9% · Observed 23.4% · Expected 26.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-11 · Fire 2024-07-11
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-05-14 · Fire 2021-05-14
2 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
4 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-08-21
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-09-20
D · Potential for more than minimal harm
2025-08-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-09-20
D · Potential for more than minimal harm
2025-08-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-09-20
F · Potential for more than minimal harm
2024-07-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-18
E · Potential for more than minimal harm
2024-07-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-06-18
D · Potential for more than minimal harm
2024-07-11
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 2024-06-18
D · Potential for more than minimal harm
2021-05-14
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2021-06-08
D · Potential for more than minimal harm
2021-05-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-06-08
D · Potential for more than minimal harm
2021-05-14
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 2021-06-08
D · Potential for more than minimal harm
2021-05-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-06-08
Inspection history
Recent health citations
K · Immediate jeopardy
2024-07-11
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 2024-07-12
K · Immediate jeopardy
2024-07-11
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 2024-07-12
J · Immediate jeopardy
2024-07-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-07-12
D · Potential for more than minimal harm
2024-07-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-12
E · Potential for more than minimal harm
2021-05-14
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-06-08
D · Potential for more than minimal harm
2021-05-14
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 2021-06-08
Penalties and ownership
What sits behind the stars
$67,987
2024-07-11
Fine
Fine · fine $67,987
Fine
Ownership
Shc LP Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Asbr Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Harrison, John
Corporate Officer · Individual
Jjla LLC
5% Or Greater Indirect Ownership Interest · Organization
Lpsnf LLC
5% Or Greater Indirect Ownership Interest · Organization
Ononye, Obinna
W-2 Managing Employee · Individual
Smedra, Ira
5% Or Greater Indirect Ownership Interest · Individual
Steier Iii, Elmer
5% Or Greater Indirect Ownership Interest · Individual
Wheaten LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Bardstown Health & Rehabilitation
Bardstown, KY
2-star overall rating with 2-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Loretto Living Center At Loretto Motherhouse, Inc
Nerinx, KY
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
#3
Sansbury Care Center
Saint Catharine, KY
5-star overall rating with 4-star inspections with $5,346 in total fines with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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