Cycle 1
Health 2025-01-24 · Fire 2025-01-24
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Columbia, KY
Signature Healthcare at Summit Manor Rehab & Welln
4-star overall rating with 4-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
400 Bomar Heights, Columbia, KY
(270) 384-2153
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
104
Certified beds
Average residents
87
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Signature Healthcare
Operator or chain grouping
Approved since
1967-06-27
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
0.59
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
2.17
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.62
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.45
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
2.99
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
0.06
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
3.47
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,523
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.91
Composite VBP score used to determine payment impact.
Payment multiplier
0.9894
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.86
Baseline 21.07% · Performance 20.57% · Measure score 1.86 · Achievement 1.86 · Improvement 0.74
Healthcare-associated infections
4.70
Baseline 9.36% · Performance 7.09% · Measure score 4.70 · Achievement 2.49 · Improvement 4.70
Total nurse turnover
4.97
Baseline 65.48% · Performance 43.37% · Measure score 4.97 · Achievement 4.97 · Improvement 4.94
Adjusted total nurse staffing
2.83
Baseline 3.66 hours · Performance 3.88 hours · Measure score 2.83 · Achievement 2.83 · Improvement 0.56
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.25% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 122 · Observed rate 14.75% · Lower 95% interval 9.2% |
| Discharge to community | 50.66% |
50.57%
0.1 pts better
|
No Different than the National Rate · Eligible stays 118 · Observed rate 44.07% · Lower 95% interval 43.62% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.28% |
95.27%
3 pts better
|
Numerator 57 · Denominator 58 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 58 |
| Discharge self-care score | 48.65% |
53.69%
5 pts worse
|
Numerator 18 · Denominator 37 |
| Discharge mobility score | 32.43% |
50.94%
18.5 pts worse
|
Numerator 12 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 6.9% |
2.29%
4.6 pts worse
|
Numerator 4 · Denominator 58 · Adjusted rate 5.71% |
| Healthcare-associated infections requiring hospitalization | 7.09% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 84 · Observed rate 5.95% · Lower 95% interval 4.3% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 89 |
| Staff flu vaccination coverage | 14.05% |
42%
27.9 pts worse
|
Numerator 17 · Denominator 121 |
| Discharge function score | 51.35% |
56.45%
5.1 pts worse
|
Numerator 19 · Denominator 37 |
| Transfer of health information to provider | 52.38% |
95.95%
43.6 pts worse
|
Numerator 11 · Denominator 21 |
| 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 | 4.76% |
25.2%
20.4 pts worse
|
Numerator 1 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.9
1.1 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
2.2
0.3 pts better
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.7 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.0% |
94.3%
7.3 pts worse
|
93.4%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 80.3% · Q2 81.8% · Q3 88.7% · Q4 95.8% · 4Q avg 87.0% |
| 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 | 3.7% |
3.8%
0.1 pts better
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 4.5% · Q3 4.2% · Q4 1.4% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 15.9% |
15.2%
0.7 pts worse
|
11.4%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 10.9% · Q3 21.0% · Q4 21.3% · 4Q avg 15.9% |
| Percentage of long-stay residents who lose too much weight | 10.9% |
6.7%
4.2 pts worse
|
5.4%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 12.5% · Q3 18.5% · Q4 8.8% · 4Q avg 10.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 45.3% |
29.6%
15.7 pts worse
|
19.6%
25.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.5% · Q2 44.6% · Q3 44.9% · Q4 44.3% · 4Q avg 45.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.3% |
17.6%
0.3 pts better
|
16.7%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 15.7% · Q3 16.7% · Q4 19.0% · 4Q avg 17.3% · 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 | 12.0% |
17.3%
5.3 pts better
|
16.3%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 12.3% · Q3 9.1% · Q4 18.3% · 4Q avg 12.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.1% |
15.6%
1.5 pts better
|
14.9%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 8.3% · Q3 13.4% · Q4 24.2% · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.7%
0.4 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.3% · 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 1.7% · Q2 0.0% · Q3 0.0% · 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 | 20.5% |
19.8%
0.7 pts worse
|
19.8%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 19.7% · Q3 13.8% · Q4 22.3% · 4Q avg 20.5% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
5.5%
2.2 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 2.7% · Q3 5.8% · Q4 1.3% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.1% |
83.8%
12.3 pts better
|
81.7%
14.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.8% · Q2 97.9% · Q3 97.0% · Q4 94.7% · 4Q avg 96.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.8% |
13.9%
4.1 pts better
|
12.0%
2.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.8% · Observed 9.8% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.5% |
1.8%
0.7 pts worse
|
1.6%
0.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 1.7% · Q3 3.5% · Q4 1.7% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.0% |
83.6%
9.4 pts better
|
79.7%
13.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.4% |
24.5%
7.1 pts better
|
23.9%
6.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.4% · Observed 16.4% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-17 · Fire 2019-10-17
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2018-09-13 · Fire 2018-09-13
6 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-01-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-24
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 2025-02-11
D · Potential for more than minimal harm
2019-10-17
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2019-11-15
D · Potential for more than minimal harm
2019-10-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-11-15
D · Potential for more than minimal harm
2019-10-17
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 2019-11-15
D · Potential for more than minimal harm
2019-10-17
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 2019-11-15
D · Potential for more than minimal harm
2018-09-13
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 2018-09-19
D · Potential for more than minimal harm
2018-09-13
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2018-09-19
D · Potential for more than minimal harm
2018-09-13
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 2018-09-19
D · Potential for more than minimal harm
2018-09-13
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2018-09-19
D · Potential for more than minimal harm
2018-09-13
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 2018-09-19
D · Potential for more than minimal harm
2018-09-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-09-19
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
Morgeson, Misty
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
Green River Trails
Greensburg, KY
3-star overall rating with 4-star inspections with $12,645 in total fines with 2 fire-safety deficiencies in the latest cycle
#2
Fair Oaks Health and Rehabilitation
Jamestown, KY
4-star overall rating with 4-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
The Grandview Nursing and Rehabilitation Facility
Campbellsville, KY
4-star overall rating with 4-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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