Cycle 1
Health 2025-07-31 · Fire 2025-07-31
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lawrenceburg, KY
Signature Healthcare at Heritage Hall Rehab & Well
1-star overall rating with 1-star inspections with $185,227 in total fines with 4 recent health deficiencies
331 South Main Street, Lawrenceburg, KY
(502) 839-7246
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
94
Certified beds
Average residents
83
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Signature Healthcare
Operator or chain grouping
Approved since
1991-05-16
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
0.87
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.97
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.22
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
4.06
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.84
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.44
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.74
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.83
CMS adjusted RN staffing hours
Adjusted total hours
3.89
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
27%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,789
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.69
Composite VBP score used to determine payment impact.
Payment multiplier
0.9866
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.51
Baseline 22.77% · Performance 21.62% · Measure score 1.51 · Achievement 0 · Improvement 1.51
Healthcare-associated infections
2.94
Baseline 6.98% · Performance 6.96% · Measure score 2.94 · Achievement 2.94 · Improvement 0
Total nurse turnover
4.78
Baseline 78.09% · Performance 50.00% · Measure score 4.78 · Achievement 3.35 · Improvement 4.78
Adjusted total nurse staffing
3.45
Baseline 3.99 hours · Performance 4.06 hours · Measure score 3.45 · Achievement 3.45 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.74% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 139 · Observed rate 12.23% · Lower 95% interval 8.42% |
| Discharge to community | 63.91% |
50.57%
13.3 pts better
|
Better than the National Rate · Eligible stays 122 · Observed rate 59.84% · Lower 95% interval 52.39% |
| Medicare spending per beneficiary | 0.78 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 91.55% |
95.27%
3.7 pts worse
|
Numerator 65 · Denominator 71 |
| Falls with major injury | 1.41% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 71 |
| Discharge self-care score | 40.82% |
53.69%
12.9 pts worse
|
Numerator 20 · Denominator 49 |
| Discharge mobility score | 38.78% |
50.94%
12.2 pts worse
|
Numerator 19 · Denominator 49 |
| Pressure ulcers or injuries, new or worsened | 1.41% |
2.29%
0.9 pts better
|
Numerator 1 · Denominator 71 · Adjusted rate 1.33% |
| Healthcare-associated infections requiring hospitalization | 6.96% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 66 · Observed rate 6.06% · Lower 95% interval 4.06% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 100 |
| Staff flu vaccination coverage | 0.65% |
42%
41.4 pts worse
|
Numerator 1 · Denominator 155 |
| Discharge function score | 42.86% |
56.45%
13.6 pts worse
|
Numerator 21 · Denominator 49 |
| 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 | 81.58% |
96.28%
14.7 pts worse
|
Numerator 31 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 36.11% |
25.2%
10.9 pts better
|
Numerator 13 · Denominator 36 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.9
0.3 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.0 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
2.2
0.1 pts better
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.4 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
94.3%
3.9 pts better
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 98.5% · Q3 100.0% · Q4 98.6% · 4Q avg 98.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.9% |
96.2%
0.3 pts worse
|
95.5%
0.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
3.8%
0.2 pts better
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.0% · Q3 4.5% · Q4 4.2% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
15.2%
14 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 1.7% · Q4 1.5% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 8.2% |
6.7%
1.5 pts worse
|
5.4%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 12.7% · Q3 3.3% · Q4 7.6% · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 37.6% |
29.6%
8 pts worse
|
19.6%
18 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.3% · Q2 40.6% · Q3 39.1% · Q4 35.8% · 4Q avg 37.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.2% |
17.6%
7.4 pts better
|
16.7%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 7.4% · Q3 10.5% · Q4 14.0% · 4Q avg 10.2% · 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 | 20.9% |
17.3%
3.6 pts worse
|
16.3%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 18.1% · Q4 21.6% · 4Q avg 20.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.1% |
15.6%
1.5 pts worse
|
14.9%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 18.6% · Q3 10.2% · Q4 18.6% · 4Q avg 17.1% · 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 | 0.8% |
1.7%
0.9 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 1.4% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.4% |
19.8%
2.4 pts better
|
19.8%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 19.4% · Q3 13.0% · Q4 17.5% · 4Q avg 17.4% |
| Percentage of long-stay residents with pressure ulcers | 4.2% |
5.5%
1.3 pts better
|
5.1%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 4.6% · Q3 1.3% · Q4 5.9% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.2% |
83.8%
8.4 pts better
|
81.7%
10.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 85.8% · Q2 91.7% · Q3 97.5% · Q4 93.0% · 4Q avg 92.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.9% |
13.9%
About the same
|
12.0%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.9% · Observed 13.5% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.8%
0.1 pts better
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.6% · Q3 1.6% · Q4 1.9% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.5% |
83.6%
0.9 pts better
|
79.7%
4.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.4% |
24.5%
0.1 pts better
|
23.9%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 23.0% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-10-28 · Fire 2021-10-28
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2019-03-21 · Fire 2019-03-21
14 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2021-10-28
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2021-12-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-31
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 2025-08-13
D · Potential for more than minimal harm
2025-07-31
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-08-13
D · Potential for more than minimal harm
2025-07-31
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 2025-08-13
D · Potential for more than minimal harm
2025-07-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-13
J · Immediate jeopardy
2023-09-29
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-10-25
J · Immediate jeopardy
2023-09-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-10-25
J · Immediate jeopardy
2023-09-29
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 2023-10-25
J · Immediate jeopardy
2023-09-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-25
J · Immediate jeopardy
2023-09-29
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-10-25
E · Potential for more than minimal harm
2023-09-29
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 2023-10-25
D · Potential for more than minimal harm
2023-09-29
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 2023-10-25
D · Potential for more than minimal harm
2023-09-29
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 2023-10-25
D · Potential for more than minimal harm
2023-09-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-10-25
D · Potential for more than minimal harm
2021-10-28
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 2021-12-02
D · Potential for more than minimal harm
2021-10-28
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 2021-12-02
D · Potential for more than minimal harm
2019-03-21
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 2019-04-30
D · Potential for more than minimal harm
2019-03-21
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 2019-04-30
D · Potential for more than minimal harm
2019-03-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-04-30
D · Potential for more than minimal harm
2019-03-21
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 2019-04-30
D · Potential for more than minimal harm
2019-03-21
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 2019-04-30
Penalties and ownership
What sits behind the stars
$185,227
2023-09-29
Fine
Fine · fine $185,227
Fine
$0
2023-09-29
Payment Denial
Payment Denial · denial start 2023-10-04 · 21 days
21 day denial
Ownership
Shc LP Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Asbr Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Colllier, Lisa
W-2 Managing Employee · Individual
Harrison, John
Corporate Officer · Individual
Jjla LLC
5% Or Greater Indirect Ownership Interest · Organization
Lpsnf LLC
5% Or Greater Indirect Ownership Interest · Organization
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
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Frankfort Trails
Frankfort, KY
2-star overall rating with 3-star inspections with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
The Home Place At Midway
Midway, KY
3-star overall rating with 2-star inspections with $4,147 in total fines with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
The Willows at Harrodsburg
Harrodsburg, KY
3-star overall rating with 2-star inspections with $12,529 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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