Cycle 1
Health 2024-05-11 · Fire 2024-05-11
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Tompkinsville, KY
Signature Healthcare of Monroe County Rehab and We
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
706 North Magnolia Street, Tompkinsville, KY
(270) 487-6135
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
75
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Signature Healthcare
Operator or chain grouping
Approved since
1982-07-01
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
0.51
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.19
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.16
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.86
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.71
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.06
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.73
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
32%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,372
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9898
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.36% · Performance 22.99% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.52
Baseline 11.16% · Performance 8.06% · Measure score 4.52 · Achievement 0 · Improvement 4.52
Total nurse turnover
7.32
Baseline 49.41% · Performance 33.75% · Measure score 7.32 · Achievement 7.32 · Improvement 5.88
Adjusted total nurse staffing
2.72
Baseline 3.67 hours · Performance 3.85 hours · Measure score 2.72 · Achievement 2.72 · Improvement 0.36
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.72% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 118 · Observed rate 11.86% · Lower 95% interval 8.45% |
| Discharge to community | 42.66% |
50.57%
7.9 pts worse
|
Worse than the National Rate · Eligible stays 124 · Observed rate 36.29% · Lower 95% interval 35.66% |
| Medicare spending per beneficiary | 1.26 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 98.8% |
95.27%
3.5 pts better
|
Numerator 82 · Denominator 83 |
| Falls with major injury | 1.2% |
0.77%
0.4 pts worse
|
Numerator 1 · Denominator 83 |
| Discharge self-care score | 44.07% |
53.69%
9.6 pts worse
|
Numerator 26 · Denominator 59 |
| Discharge mobility score | 40.68% |
50.94%
10.3 pts worse
|
Numerator 24 · Denominator 59 |
| Pressure ulcers or injuries, new or worsened | 2.41% |
2.29%
0.1 pts worse
|
Numerator 2 · Denominator 83 · Adjusted rate 2.16% |
| Healthcare-associated infections requiring hospitalization | 8.07% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 73 · Observed rate 8.22% · Lower 95% interval 5.41% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 94 |
| Staff flu vaccination coverage | 16.53% |
42%
25.5 pts worse
|
Numerator 20 · Denominator 121 |
| Discharge function score | 59.32% |
56.45%
2.9 pts better
|
Numerator 35 · Denominator 59 |
| Transfer of health information to provider | 90.91% |
95.95%
5 pts worse
|
Numerator 20 · Denominator 22 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 26 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 24.39% |
25.2%
0.8 pts worse
|
Numerator 10 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.9
0.6 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
2.2
0.5 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.7 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
94.3%
3.5 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 93.8% · Q2 97.1% · Q3 100.0% · Q4 100.0% · 4Q avg 97.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
96.2%
2.4 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.5% |
3.8%
0.7 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.9% · Q3 6.0% · Q4 7.5% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 16.1% |
15.2%
0.9 pts worse
|
11.4%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 9.8% · Q3 23.7% · Q4 18.6% · 4Q avg 16.1% |
| Percentage of long-stay residents who lose too much weight | 6.0% |
6.7%
0.7 pts better
|
5.4%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.5% · Q3 8.1% · Q4 13.3% · 4Q avg 6.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.6% |
29.6%
3 pts worse
|
19.6%
13 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 30.9% · Q3 32.8% · Q4 35.9% · 4Q avg 32.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.5% |
17.6%
2.9 pts worse
|
16.7%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 22.4% · Q3 21.6% · Q4 15.7% · 4Q avg 20.5% · 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 | 6.4% |
17.3%
10.9 pts better
|
16.3%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 3.8% · Q3 3.7% · Q4 14.0% · 4Q avg 6.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.6% |
15.6%
4 pts better
|
14.9%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 6.6% · Q3 15.5% · Q4 18.2% · 4Q avg 11.6% · 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 | 16.8% |
19.8%
3 pts better
|
19.8%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 25.5% · Q3 13.0% · Q4 16.6% · 4Q avg 16.8% |
| Percentage of long-stay residents with pressure ulcers | 7.4% |
5.5%
1.9 pts worse
|
5.1%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 7.4% · Q3 6.6% · Q4 5.1% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.1% |
83.8%
5.7 pts worse
|
81.7%
3.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 67.8% · Q2 73.4% · Q3 78.3% · Q4 90.4% · 4Q avg 78.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.1% |
13.9%
6.8 pts better
|
12.0%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.1% · Observed 7.3% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.8%
1.2 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.4% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 72.1% |
83.6%
11.5 pts worse
|
79.7%
7.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 72.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.5% |
24.5%
1 pts better
|
23.9%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.5% · Observed 22.0% · Expected 22.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-04-18 · Fire 2019-04-18
1 health deficiencies
Top issue: Infection Control (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2018-03-08 · Fire 2018-03-08
5 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-07-29
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-07-30
F · Potential for more than minimal harm
2024-05-11
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2024-06-05
F · Potential for more than minimal harm
2024-05-11
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-06-05
F · Potential for more than minimal harm
2024-05-11
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-06-05
E · Potential for more than minimal harm
2024-05-11
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-06-05
E · Potential for more than minimal harm
2024-05-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-05
D · Potential for more than minimal harm
2024-05-11
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 2024-06-05
D · Potential for more than minimal harm
2024-05-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-06-05
F · Potential for more than minimal harm
2019-04-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-04-18
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-05-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-05-31
D · Potential for more than minimal harm
2019-04-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-05-18
E · Potential for more than minimal harm
2018-03-08
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 2018-04-09
E · Potential for more than minimal harm
2018-03-08
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 2018-04-09
D · Potential for more than minimal harm
2018-03-08
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 2018-04-09
D · Potential for more than minimal harm
2018-03-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-04-09
C · Minimal harm
2018-03-08
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2018-04-09
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
Spears, Candi
Operational/Managerial Control · 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
Red Boiling Springs Tn Opco LLC
Red Boiling Springs, TN
2-star overall rating with 2-star inspections with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Celina Health And Rehabilitation Center
Celina, TN
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Cumberland Valley Nursing & Rehabilitation Center
Burkesville, KY
1-star overall rating with 2-star inspections with $24,385 in total fines with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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