Cycle 1
Health 2024-10-04 · Fire 2024-10-04
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Louisville, KY
Signature Healthcare at Rockford Rehab & Wellness
4-star overall rating with 3-star inspections with 1 recent health deficiencies
4700 Quinn Drive, Louisville, KY
(502) 448-5850
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
96
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Signature Healthcare
Operator or chain grouping
Approved since
1991-12-01
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
0.63
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.31
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.69
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
3.34
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,712
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.92
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.92
Performance 20.08% · Measure score 2.92 · Achievement 2.92 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
1.44
Baseline 5.60% · Performance 7.40% · Measure score 1.44 · Achievement 1.44 · Improvement 0
Total nurse turnover
0
Baseline 47.37% · Performance 62.14% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.11 hours · Performance 3.13 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.24% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 68 · Observed rate 11.76% · Lower 95% interval 7.14% |
| Discharge to community | 53.82% |
50.57%
3.2 pts better
|
No Different than the National Rate · Eligible stays 73 · Observed rate 41.1% · Lower 95% interval 41.9% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 83.87% |
95.27%
11.4 pts worse
|
Numerator 26 · Denominator 31 |
| Falls with major injury | 6.45% |
0.77%
5.7 pts worse
|
Numerator 2 · Denominator 31 |
| Discharge self-care score | 47.83% |
53.69%
5.9 pts worse
|
Numerator 11 · Denominator 23 |
| Discharge mobility score | 30.43% |
50.94%
20.5 pts worse
|
Numerator 7 · Denominator 23 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 31 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.4% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 39 · Observed rate 10.26% · Lower 95% interval 3.77% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 83 |
| Staff flu vaccination coverage | 15.72% |
42%
26.3 pts worse
|
Numerator 25 · Denominator 159 |
| Discharge function score | 43.48% |
56.45%
13 pts worse
|
Numerator 10 · Denominator 23 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.5% |
94.3%
5.8 pts worse
|
93.4%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 87.8% · Q2 90.9% · Q3 87.8% · Q4 87.6% · 4Q avg 88.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.6% |
96.2%
1.6 pts worse
|
95.5%
0.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
3.8%
1.6 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.1% · Q3 3.3% · Q4 2.2% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 21.6% |
15.2%
6.4 pts worse
|
11.4%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 20.3% · Q3 22.1% · Q4 27.8% · 4Q avg 21.6% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
6.7%
2.7 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 2.3% · Q3 4.5% · Q4 5.6% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.0% |
29.6%
14.6 pts better
|
19.6%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 12.6% · Q3 13.5% · Q4 19.1% · 4Q avg 15.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.1% |
17.6%
12.5 pts better
|
16.7%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 5.9% · Q3 4.3% · Q4 2.8% · 4Q avg 5.1% · 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 | 7.5% |
17.3%
9.8 pts better
|
16.3%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 4.6% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.6% |
15.6%
5 pts better
|
14.9%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 4.9% · Q3 5.1% · Q4 5.4% · 4Q avg 10.6% · 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 | 0.0% |
1.7%
1.7 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 20.9% |
19.8%
1.1 pts worse
|
19.8%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.0% · Q2 20.5% · Q3 23.7% · Q4 12.4% · 4Q avg 20.9% |
| Percentage of long-stay residents with pressure ulcers | 7.5% |
5.5%
2 pts worse
|
5.1%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 9.2% · Q3 7.2% · Q4 5.9% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 60.5% |
83.8%
23.3 pts worse
|
81.7%
21.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 46.9% · Q2 54.5% · Q3 65.2% · Q4 81.7% · 4Q avg 60.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.6% |
13.9%
6.3 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.6% · Observed 8.3% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.8%
1.8 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 62.5% |
83.6%
21.1 pts worse
|
79.7%
17.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 62.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.0% |
24.5%
4.5 pts better
|
23.9%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.0% · Observed 20.8% · Expected 24.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-08-31 · Fire 2019-08-31
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2018-06-07 · Fire 2018-06-07
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2019-08-31
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2019-09-27
E · Potential for more than minimal harm
2019-08-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-09-27
D · Potential for more than minimal harm
2019-08-31
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-09-27
D · Potential for more than minimal harm
2019-08-31
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2019-09-27
D · Potential for more than minimal harm
2018-06-07
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2018-06-29
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-10-04
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-11-05
G · Actual harm
2019-08-31
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-10-17
G · Actual harm
2019-08-31
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-10-17
G · Actual harm
2019-08-31
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2019-10-17
E · Potential for more than minimal harm
2019-08-31
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-10-17
D · Potential for more than minimal harm
2019-08-31
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 2019-10-17
D · Potential for more than minimal harm
2019-08-31
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-10-17
D · Potential for more than minimal harm
2019-08-31
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 2019-10-17
D · Potential for more than minimal harm
2019-08-31
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2019-10-17
E · Potential for more than minimal harm
2018-06-07
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 2018-06-12
D · Potential for more than minimal harm
2018-06-07
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 2018-06-12
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
Signature Healthcare LLC
Operational/Managerial Control · Organization
Smedra, Ira
5% Or Greater Indirect Ownership Interest · Individual
Smith, Dawn
W-2 Managing Employee · 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 Summerfield Rehab & Wellne
Louisville, KY
1-star overall rating with 1-star inspections with $182,488 in total fines
#2
Parkwood Health & Rehabilitation
Louisville, KY
1-star overall rating with 1-star inspections with $10,209 in total fines with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Signature Healthcare of South Louisville
Louisville, KY
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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