Cycle 1
Health 2025-07-25 · Fire 2025-07-25
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Louisville, KY
Signature Healthcare at Jefferson Manor Rehab & We
5-star overall rating with 4-star inspections with 1 recent health deficiencies
1801 Lynn Way, Louisville, KY
(502) 426-4513
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
93
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Signature Healthcare
Operator or chain grouping
Approved since
1982-09-02
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
0.79
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.19
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.84
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.65
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.14
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.76
CMS adjusted RN staffing hours
Adjusted total hours
3.68
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,884
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.87
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.26
Baseline 22.19% · Performance 20.77% · Measure score 2.26 · Achievement 1.43 · Improvement 2.26
Healthcare-associated infections
0.63
Baseline 7.17% · Performance 7.65% · Measure score 0.63 · Achievement 0.63 · Improvement 0
Total nurse turnover
1.26
Baseline 48.15% · Performance 58.54% · Measure score 1.26 · Achievement 1.26 · Improvement 0
Adjusted total nurse staffing
1.81
Baseline 2.82 hours · Performance 3.50 hours · Measure score 1.81 · Achievement 1.49 · Improvement 1.81
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.94% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 143 · Observed rate 10.49% · Lower 95% interval 7.46% |
| Discharge to community | 60.59% |
50.57%
10 pts better
|
Better than the National Rate · Eligible stays 132 · Observed rate 48.48% · Lower 95% interval 50.82% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.81% |
95.27%
3.5 pts better
|
Numerator 83 · Denominator 84 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 84 |
| Discharge self-care score | 71.67% |
53.69%
18 pts better
|
Numerator 43 · Denominator 60 |
| Discharge mobility score | 71.67% |
50.94%
20.7 pts better
|
Numerator 43 · Denominator 60 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 84 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.65% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 79 · Observed rate 10.13% · Lower 95% interval 4.99% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 92 |
| Staff flu vaccination coverage | 30.23% |
42%
11.8 pts worse
|
Numerator 52 · Denominator 172 |
| Discharge function score | 76.67% |
56.45%
20.2 pts better
|
Numerator 46 · Denominator 60 |
| Transfer of health information to provider | 94.87% |
95.95%
1.1 pts worse
|
Numerator 37 · Denominator 39 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 26 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 39.22% |
25.2%
14 pts better
|
Numerator 20 · Denominator 51 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.9
1 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 2.0 · 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 0.9 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
94.3%
3 pts better
|
93.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.4% · Q2 100.0% · Q3 98.6% · Q4 97.6% · 4Q avg 97.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.7% |
96.2%
2.5 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
3.8%
1.4 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.3% · Q3 4.2% · Q4 2.4% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.2% |
15.2%
11 pts better
|
11.4%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 1.6% · Q3 6.5% · Q4 5.2% · 4Q avg 4.2% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
6.7%
1.4 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 4.1% · Q3 7.1% · Q4 3.9% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.5% |
29.6%
15.1 pts better
|
19.6%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 17.3% · Q3 11.4% · Q4 13.9% · 4Q avg 14.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.8% |
17.6%
9.8 pts better
|
16.7%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 8.3% · Q3 4.9% · Q4 7.5% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.3% |
0.2%
0.1 pts worse
|
0.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.4% |
17.3%
11.9 pts better
|
16.3%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 14.2% · Q3 4.4% · Q4 3.1% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.9% |
15.6%
8.7 pts better
|
14.9%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 10.1% · Q3 3.0% · Q4 3.9% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.7%
0.1 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.2% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.7%
1.4 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.7% |
19.8%
2.9 pts worse
|
19.8%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 23.0% · Q3 24.8% · Q4 26.5% · 4Q avg 22.7% |
| Percentage of long-stay residents with pressure ulcers | 6.1% |
5.5%
0.6 pts worse
|
5.1%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 6.9% · Q3 7.6% · Q4 6.3% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.2% |
83.8%
10.4 pts better
|
81.7%
12.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.6% · Q2 95.1% · Q3 95.9% · Q4 97.4% · 4Q avg 94.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.3% |
13.9%
8.6 pts better
|
12.0%
6.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.3% · Observed 7.1% · Expected 15.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
1.8%
0.9 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 3.0% · Q3 1.4% · Q4 1.7% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.7% |
83.6%
2.1 pts better
|
79.7%
6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.0% |
24.5%
6.5 pts worse
|
23.9%
7.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.0% · Observed 38.6% · Expected 29.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-06 · Fire 2024-06-06
6 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-02-15 · Fire 2019-02-15
7 health deficiencies
Top issue: Infection Control (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2019-02-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-03-22
D · Potential for more than minimal harm
2019-02-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-04-02
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-25
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-08-19
E · Potential for more than minimal harm
2024-06-06
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 2024-07-02
D · Potential for more than minimal harm
2024-06-06
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-06-06
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-06-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-02
D · Potential for more than minimal harm
2024-06-06
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 2024-07-02
D · Potential for more than minimal harm
2024-06-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-02
F · Potential for more than minimal harm
2019-02-15
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 2019-04-02
D · Potential for more than minimal harm
2019-02-15
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 2019-04-02
D · Potential for more than minimal harm
2019-02-15
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 2019-04-02
D · Potential for more than minimal harm
2019-02-15
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2019-04-02
D · Potential for more than minimal harm
2019-02-15
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 2019-04-02
D · Potential for more than minimal harm
2019-02-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-04-02
D · Potential for more than minimal harm
2019-02-15
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2019-04-02
Penalties and ownership
What sits behind the stars
Ownership
Shc LP Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Asbr Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Cooper, Robert
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
#1
Signature Healthcare at Jefferson Place Rehab & We
Louisville, KY
4-star overall rating with 3-star inspections with 1 recent health deficiencies
#2
The Episcopal Church Home
Louisville, KY
4-star overall rating with 3-star inspections with 1 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Lyndon Crossing
Louisville, KY
0-star overall rating with 0-star inspections with Special Focus status with $20,563 in total fines with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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