Cycle 1
Health 2025-06-18 · Fire 2025-06-18
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Louisville, KY
Signature Healthcare at Jefferson Place Rehab & We
4-star overall rating with 3-star inspections with 1 recent health deficiencies
1705 Herr Lane, Louisville, KY
(502) 426-5600
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
95
Certified beds
Average residents
81
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Signature Healthcare
Operator or chain grouping
Approved since
1992-05-18
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
0.92
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.07
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.90
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.83
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.36
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.94
CMS adjusted RN staffing hours
Adjusted total hours
3.95
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
32%
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
2,581
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.92
Composite VBP score used to determine payment impact.
Payment multiplier
1.0028
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.95
Baseline 20.75% · Performance 20.06% · Measure score 2.95 · Achievement 2.95 · Improvement 1.33
Healthcare-associated infections
8.56
Baseline 5.85% · Performance 5.28% · Measure score 8.56 · Achievement 8.56 · Improvement 6.19
Total nurse turnover
5.49
Baseline 29.87% · Performance 41.25% · Measure score 5.49 · Achievement 5.49 · Improvement 0
Adjusted total nurse staffing
2.57
Baseline 3.84 hours · Performance 3.81 hours · Measure score 2.57 · Achievement 2.57 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.71% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 433 · Observed rate 11.78% · Lower 95% interval 9.02% |
| Discharge to community | 62.53% |
50.57%
12 pts better
|
Better than the National Rate · Eligible stays 407 · Observed rate 57% · Lower 95% interval 56.57% |
| Medicare spending per beneficiary | 0.78 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.11% |
95.27%
1.8 pts better
|
Numerator 235 · Denominator 242 |
| Falls with major injury | 0.83% |
0.77%
0.1 pts worse
|
Numerator 2 · Denominator 242 |
| Discharge self-care score | 62.5% |
53.69%
8.8 pts better
|
Numerator 90 · Denominator 144 |
| Discharge mobility score | 47.22% |
50.94%
3.7 pts worse
|
Numerator 68 · Denominator 144 |
| Pressure ulcers or injuries, new or worsened | 2.48% |
2.29%
0.2 pts worse
|
Numerator 6 · Denominator 242 · Adjusted rate 3.05% |
| Healthcare-associated infections requiring hospitalization | 5.28% |
7.12%
1.8 pts better
|
No Different than the National Rate · Eligible stays 256 · Observed rate 3.52% · Lower 95% interval 3.45% |
| Staff COVID-19 vaccination coverage | 3.7% |
8.2%
4.5 pts worse
|
Numerator 4 · Denominator 108 |
| Staff flu vaccination coverage | 12.35% |
42%
29.6 pts worse
|
Numerator 21 · Denominator 170 |
| Discharge function score | 52.78% |
56.45%
3.7 pts worse
|
Numerator 76 · Denominator 144 |
| Transfer of health information to provider | 94% |
95.95%
2 pts worse
|
Numerator 47 · Denominator 50 |
| Transfer of health information to patient | 91.46% |
96.28%
4.8 pts worse
|
Numerator 150 · Denominator 164 |
| Resident COVID-19 vaccinations up to date | 19.05% |
25.2%
6.1 pts worse
|
Numerator 20 · Denominator 105 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.9
0.9 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.3 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
2.2
1.9 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.3 · Observed 0.4 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.7% |
94.3%
2.6 pts worse
|
93.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 85.7% · Q2 93.8% · Q3 95.7% · Q4 91.7% · 4Q avg 91.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
96.2%
1.8 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| 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 0.0% · Q2 0.0% · Q3 2.1% · Q4 2.1% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.8% |
15.2%
3.4 pts better
|
11.4%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 14.0% · Q3 16.3% · Q4 7.0% · 4Q avg 11.8% |
| Percentage of long-stay residents who lose too much weight | 5.7% |
6.7%
1 pts better
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 9.5% · Q3 7.9% · Q4 0.0% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.3% |
29.6%
14.3 pts better
|
19.6%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 11.6% · Q3 17.9% · Q4 23.7% · 4Q avg 15.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.9% |
17.6%
4.7 pts better
|
16.7%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 13.9% · Q3 12.9% · Q4 13.3% · 4Q avg 12.9% · 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 | 14.1% |
17.3%
3.2 pts better
|
16.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.2% |
15.6%
0.4 pts better
|
14.9%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 7.3% · Q3 10.5% · Q4 18.9% · 4Q avg 15.2% · 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 | 1.1% |
1.7%
0.6 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.2% |
19.8%
0.4 pts worse
|
19.8%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 21.0% · Q3 16.4% · Q4 22.9% · 4Q avg 20.2% |
| Percentage of long-stay residents with pressure ulcers | 10.0% |
5.5%
4.5 pts worse
|
5.1%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 11.2% · Q3 9.1% · Q4 10.6% · 4Q avg 10.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
83.8%
11.9 pts better
|
81.7%
14 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.6% · Q2 95.0% · Q3 97.2% · Q4 96.2% · 4Q avg 95.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.3% |
13.9%
6.6 pts better
|
12.0%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.3% · Observed 7.0% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.8%
0.4 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.7% · Q3 1.1% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.3% |
83.6%
4.7 pts better
|
79.7%
8.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.1% |
24.5%
0.4 pts better
|
23.9%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 22.1% · Expected 21.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-09-18 · Fire 2021-09-18
3 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-03-08 · Fire 2019-03-08
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2019-03-08
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 2019-05-02
D · Potential for more than minimal harm
2019-03-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-05-02
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-06-18
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 2025-07-10
F · Potential for more than minimal harm
2021-09-18
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 2021-10-18
E · Potential for more than minimal harm
2021-09-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-10-18
D · Potential for more than minimal harm
2021-09-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-10-18
F · Potential for more than minimal harm
2019-03-08
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 2019-05-02
E · Potential for more than minimal harm
2019-03-08
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 2019-05-02
E · Potential for more than minimal harm
2019-03-08
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 2019-05-02
D · Potential for more than minimal harm
2019-03-08
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-05-02
D · Potential for more than minimal harm
2019-03-08
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 2019-05-02
D · Potential for more than minimal harm
2019-03-08
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-05-02
D · Potential for more than minimal harm
2019-03-08
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-05-02
D · Potential for more than minimal harm
2019-03-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-05-02
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
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
Stoner, Chante
Operational/Managerial Control · Individual
Wheaten LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Signature Healthcare at Jefferson Manor Rehab & We
Louisville, KY
5-star overall rating with 4-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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