Cycle 1
Health 2024-10-25 · Fire 2024-10-25
1 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Elizabethtown, KY
Signature Healthcare of Elizabethtown
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1850 Veteran's Way, Elizabethtown, KY
(270) 769-2363
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
124
Certified beds
Average residents
117
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Signature Healthcare
Operator or chain grouping
Approved since
1972-09-01
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
0.83
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.26
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.85
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.30
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
3.41
CMS adjusted total nurse staffing hours
Case-mix index
1.54
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,917
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
9.66
Composite VBP score used to determine payment impact.
Payment multiplier
0.9808
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.04% · Performance 22.86% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.95% · Performance 8.39% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.42
Baseline 49.38% · Performance 53.79% · Measure score 2.42 · Achievement 2.42 · Improvement 0
Adjusted total nurse staffing
1.45
Baseline 3.43 hours · Performance 3.49 hours · Measure score 1.45 · Achievement 1.45 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 14.91% |
10.72%
4.2 pts worse
|
Worse than the National Rate · Eligible stays 318 · Observed rate 17.3% · Lower 95% interval 11.82% |
| Discharge to community | 51.53% |
50.57%
1 pts better
|
No Different than the National Rate · Eligible stays 330 · Observed rate 43.94% · Lower 95% interval 45.53% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.81% |
95.27%
2.5 pts better
|
Numerator 268 · Denominator 274 |
| Falls with major injury | 0.36% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 274 |
| Discharge self-care score | 59.41% |
53.69%
5.7 pts better
|
Numerator 120 · Denominator 202 |
| Discharge mobility score | 56.93% |
50.94%
6 pts better
|
Numerator 115 · Denominator 202 |
| Pressure ulcers or injuries, new or worsened | 1.46% |
2.29%
0.8 pts better
|
Numerator 4 · Denominator 274 · Adjusted rate 1.36% |
| Healthcare-associated infections requiring hospitalization | 8.39% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 266 · Observed rate 9.02% · Lower 95% interval 6.27% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 152 |
| Staff flu vaccination coverage | 31.09% |
42%
10.9 pts worse
|
Numerator 74 · Denominator 238 |
| Discharge function score | 62.38% |
56.45%
5.9 pts better
|
Numerator 126 · Denominator 202 |
| Transfer of health information to provider | 96.77% |
95.95%
0.8 pts better
|
Numerator 60 · Denominator 62 |
| Transfer of health information to patient | 95.51% |
96.28%
0.8 pts worse
|
Numerator 170 · Denominator 178 |
| Resident COVID-19 vaccinations up to date | 18.94% |
25.2%
6.3 pts worse
|
Numerator 25 · Denominator 132 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.9
0.8 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.3 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
2.2
1.4 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.9 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.8% |
94.3%
12.5 pts worse
|
93.4%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 72.9% · Q2 73.6% · Q3 90.2% · Q4 90.8% · 4Q avg 81.8% |
| 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 | 2.6% |
3.8%
1.2 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 4.6% · Q3 0.0% · Q4 1.1% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.1% |
15.2%
3.1 pts better
|
11.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 2.5% · Q4 42.9% · 4Q avg 12.1% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
6.7%
1.7 pts better
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 3.9% · Q3 4.2% · Q4 6.4% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.0% |
29.6%
4.6 pts better
|
19.6%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.8% · Q2 25.6% · Q3 26.0% · Q4 20.5% · 4Q avg 25.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.9% |
17.6%
1.7 pts better
|
16.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 16.7% · Q3 18.4% · Q4 15.4% · 4Q avg 15.9% · 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 | 13.4% |
17.3%
3.9 pts better
|
16.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.4% |
15.6%
5.2 pts better
|
14.9%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 15.1% · Q3 9.1% · Q4 5.7% · 4Q avg 10.4% · 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 | 16.7% |
19.8%
3.1 pts better
|
19.8%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 14.5% · Q3 19.4% · Q4 14.4% · 4Q avg 16.7% |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
5.5%
3.3 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 2.8% · Q3 0.0% · Q4 2.4% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.9% |
83.8%
11.1 pts better
|
81.7%
13.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.2% · Q2 93.5% · Q3 95.1% · Q4 95.7% · 4Q avg 94.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.2% |
13.9%
0.7 pts better
|
12.0%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.2% · Observed 13.7% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.8%
1.3 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.7% · Q3 0.7% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.1% |
83.6%
15.5 pts better
|
79.7%
19.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.9% |
24.5%
1.6 pts better
|
23.9%
1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.9% · Observed 23.7% · Expected 24.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-07-01 · Fire 2021-07-01
1 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2019-05-31 · Fire 2019-05-31
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-25
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-10-25
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-10-25
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-10-25
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-12-02
D · Potential for more than minimal harm
2021-07-01
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2021-07-26
D · Potential for more than minimal harm
2021-07-01
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2021-07-26
D · Potential for more than minimal harm
2019-05-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-26
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-10-25
F606 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Not hire anyone with a finding of abuse, neglect, exploitation, or theft.
Corrected 2024-11-18
D · Potential for more than minimal harm
2023-11-08
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-12-01
D · Potential for more than minimal harm
2023-11-08
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 2023-12-01
D · Potential for more than minimal harm
2021-07-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-07-26
F · Potential for more than minimal harm
2019-05-31
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 2019-06-27
E · Potential for more than minimal harm
2019-05-31
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 2019-06-27
D · Potential for more than minimal harm
2019-05-31
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2019-06-27
D · Potential for more than minimal harm
2019-05-31
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 2019-06-27
D · Potential for more than minimal harm
2019-05-31
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-06-27
D · Potential for more than minimal harm
2019-05-31
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2019-06-27
D · Potential for more than minimal harm
2019-05-31
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 2019-06-27
Penalties and ownership
What sits behind the stars
Ownership
Shc Ky Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Asbr Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Dillard, Weslene
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
Shc LP Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Signature Healthcare LLC
Operational/Managerial Control · 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
Elizabethtown Nursing and Rehabilitation Center
Elizabethtown, KY
1-star overall rating with 2-star inspections with $4,893 in total fines with 8 recent health deficiencies
#2
Helmwood Healthcare
Elizabethtown, KY
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
#3
Kensington Nursing and Rehabilitation Center
Elizabethtown, KY
2-star overall rating with 2-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Jump out