Cycle 1
Health 2025-06-05 · Fire 2025-06-05
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Carrollton, KY
Signature Healthcare of Carrollton Rehab & Wellnes
4-star overall rating with 4-star inspections with 1 fire-safety deficiencies in the latest cycle
1206 Eleventh Street, Carrollton, KY
(502) 732-6683
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
78
Certified beds
Average residents
69
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Signature Healthcare
Operator or chain grouping
Approved since
1990-02-05
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
0.58
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.35
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.74
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.24
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.24
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
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.23
CMS adjusted total nurse staffing hours
Case-mix index
1.58
Higher values indicate more complex resident acuity
RN turnover
25%
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
9,939
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.98
Composite VBP score used to determine payment impact.
Payment multiplier
0.9828
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.94
Baseline 18.02% · Performance 20.53% · Measure score 1.94 · Achievement 1.94 · Improvement 0
Healthcare-associated infections
2.07
Baseline 7.83% · Performance 7.22% · Measure score 2.07 · Achievement 2.07 · Improvement 1.68
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
2.59
Baseline 3.92 hours · Performance 3.81 hours · Measure score 2.59 · Achievement 2.59 · Improvement 0
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 59 · Observed rate 20.34% · Lower 95% interval 8.34% |
| Discharge to community | 43.48% |
50.57%
7.1 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 32% · Lower 95% interval 33.58% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 40 · Denominator 40 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 40 |
| Discharge self-care score | 20.83% |
53.69%
32.9 pts worse
|
Numerator 5 · Denominator 24 |
| Discharge mobility score | 16.67% |
50.94%
34.3 pts worse
|
Numerator 4 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 2.5% |
2.29%
0.2 pts worse
|
Numerator 1 · Denominator 40 · Adjusted rate 2.22% |
| Healthcare-associated infections requiring hospitalization | 7.22% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 32 · Observed rate 9.38% · Lower 95% interval 4.04% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 84 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 103 |
| Discharge function score | 33.33% |
56.45%
23.1 pts worse
|
Numerator 8 · Denominator 24 |
| 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 | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 28.57% |
25.2%
3.4 pts better
|
Numerator 6 · Denominator 21 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 89.7% |
94.3%
4.6 pts worse
|
93.4%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 70.5% · Q3 88.7% · Q4 100.0% · 4Q avg 89.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.7% |
96.2%
0.5 pts worse
|
95.5%
0.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.8%
2.2 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.6% · Q3 1.6% · Q4 1.5% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 35.0% |
15.2%
19.8 pts worse
|
11.4%
23.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 33.3% · Q3 36.4% · Q4 53.4% · 4Q avg 35.0% |
| Percentage of long-stay residents who lose too much weight | 5.2% |
6.7%
1.5 pts better
|
5.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 3.8% · Q3 6.9% · Q4 5.1% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.6% |
29.6%
3 pts better
|
19.6%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.7% · Q2 32.1% · Q3 23.3% · Q4 13.3% · 4Q avg 26.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.8% |
17.6%
2.8 pts better
|
16.7%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 15.2% · Q3 15.6% · Q4 19.1% · 4Q avg 14.8% · 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 | 27.4% |
17.3%
10.1 pts worse
|
16.3%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 42.4% · Q3 8.1% · Q4 23.2% · 4Q avg 27.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.1% |
15.6%
9.5 pts worse
|
14.9%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 39.3% · Q2 24.1% · Q3 21.2% · Q4 15.1% · 4Q avg 25.1% · 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 | 0.4% |
1.7%
1.3 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.2% |
19.8%
3.6 pts better
|
19.8%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 23.4% · Q3 19.5% · Q4 12.2% · 4Q avg 16.2% |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
5.5%
0.2 pts worse
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 5.6% · Q3 3.7% · Q4 4.9% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 72.8% |
83.8%
11 pts worse
|
81.7%
8.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 68.1% · Q2 67.9% · Q3 65.0% · Q4 90.9% · 4Q avg 72.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.1% |
13.9%
6.2 pts worse
|
12.0%
8.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.1% · Observed 23.3% · Expected 13.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.3% |
1.8%
0.5 pts better
|
1.6%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 66.7% |
83.6%
16.9 pts worse
|
79.7%
13 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 66.7% |
| 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 26.7% · Expected 26.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-12 · Fire 2024-04-12
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2020-03-05 · Fire 2020-03-05
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-06-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-28
F · Potential for more than minimal harm
2024-04-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-05-26
F · Potential for more than minimal harm
2024-04-12
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-05-26
F · Potential for more than minimal harm
2020-03-05
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-05-10
E · Potential for more than minimal harm
2020-03-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-05-10
D · Potential for more than minimal harm
2020-03-05
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2020-05-10
D · Potential for more than minimal harm
2020-03-05
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2020-05-10
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-12-20
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-12-20
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 2025-01-15
D · Potential for more than minimal harm
2024-04-12
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-05-26
D · Potential for more than minimal harm
2024-04-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-26
E · Potential for more than minimal harm
2020-03-05
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2020-05-10
D · Potential for more than minimal harm
2020-03-05
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2020-05-10
D · Potential for more than minimal harm
2020-03-05
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 2020-05-10
D · Potential for more than minimal harm
2020-03-05
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 2020-05-10
D · Potential for more than minimal harm
2020-03-05
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 2020-05-10
D · Potential for more than minimal harm
2020-03-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-05-10
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
Wade, Alan
W-2 Managing Employee · Individual
Wheaten LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Swiss Villa Nursing And Rehabilitation
Vevay, IN
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Bedford Springs Health and Rehabilitation
Bedford, KY
5-star overall rating with 4-star inspections with 5 fire-safety deficiencies in the latest cycle
#3
River Terrace Health Campus
Madison, IN
2-star overall rating with 2-star inspections with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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