Cycle 1
Health 2025-01-09 · Fire 2025-01-09
1 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Edgewood, KY
St Elizabeth Edgewood SNF
5-star overall rating with 4-star inspections with 1 recent health deficiencies
1 Medical Village Drive, Edgewood, KY
(859) 301-9980
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
30
Certified beds
Average residents
23
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-01-27
CMS approved date
Coverage
Medicare
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
4.33
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
3.27
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
8.52
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
5.25
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
7.28
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
3.17
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
4.06
CMS adjusted RN staffing hours
Adjusted total hours
7.99
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
277
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
74.71
Composite VBP score used to determine payment impact.
Payment multiplier
1.0244
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.43
Baseline 18.82% · Performance 18.92% · Measure score 5.43 · Achievement 5.43 · Improvement 0
Healthcare-associated infections
10
Baseline 5.75% · Performance 4.72% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
6.98
Baseline 50.00% · Performance 35.13% · Measure score 6.98 · Achievement 6.98 · Improvement 5.41
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.37% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 196 · Observed rate 7.65% · Lower 95% interval 6.78% |
| Discharge to community | 75.38% |
50.57%
24.8 pts better
|
Better than the National Rate · Eligible stays 182 · Observed rate 74.73% · Lower 95% interval 67.02% |
| Medicare spending per beneficiary | 0.68 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 98.61% |
95.27%
3.3 pts better
|
Numerator 142 · Denominator 144 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 144 |
| Discharge self-care score | 11.4% |
53.69%
42.3 pts worse
|
Numerator 13 · Denominator 114 |
| Discharge mobility score | 5.26% |
50.94%
45.7 pts worse
|
Numerator 6 · Denominator 114 |
| Pressure ulcers or injuries, new or worsened | 1.39% |
2.29%
0.9 pts better
|
Numerator 2 · Denominator 144 · Adjusted rate 2.45% |
| Healthcare-associated infections requiring hospitalization | 4.72% |
7.12%
2.4 pts better
|
No Different than the National Rate · Eligible stays 123 · Observed rate 0.81% · Lower 95% interval 2.39% |
| Staff COVID-19 vaccination coverage | 8.11% |
8.2%
0.1 pts worse
|
Numerator 3 · Denominator 37 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 13.16% |
56.45%
43.3 pts worse
|
Numerator 15 · Denominator 114 |
| Transfer of health information to provider | 97.58% |
95.95%
1.6 pts better
|
Numerator 121 · Denominator 124 |
| Transfer of health information to patient | 90% |
96.28%
6.3 pts worse
|
Numerator 18 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 33.33% |
25.2%
8.1 pts better
|
Numerator 21 · Denominator 63 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
83.8%
14.7 pts better
|
81.7%
16.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 98.7% · Q3 100.0% · Q4 96.6% · 4Q avg 98.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.4% |
13.9%
9.5 pts better
|
12.0%
7.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.4% · Observed 4.3% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.8%
0.3 pts better
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.8% · Q3 1.5% · Q4 0.7% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.1% |
83.6%
5.5 pts better
|
79.7%
9.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.1% |
24.5%
2.4 pts better
|
23.9%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.1% · Observed 19.7% · Expected 21.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-09 · Fire 2023-11-09
2 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-08-04 · Fire 2022-08-04
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-11-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-30
F · Potential for more than minimal harm
2023-11-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-30
E · Potential for more than minimal harm
2023-11-09
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-11-30
D · Potential for more than minimal harm
2023-11-09
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-11-30
F · Potential for more than minimal harm
2022-08-04
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-09-10
F · Potential for more than minimal harm
2022-08-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-09-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-19
F · Potential for more than minimal harm
2023-11-09
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 2023-12-21
D · Potential for more than minimal harm
2023-11-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-21
F · Potential for more than minimal harm
2022-08-04
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 2022-09-10
Penalties and ownership
What sits behind the stars
Ownership
Buxton, Sylvia
Corporate Director · Individual
Colvin, Garren
Corporate Director · Individual
Colvin, Garren
Corporate Officer · Individual
Frey, Lisa
Corporate Officer · Individual
Hall, Vera
Corporate Officer · Individual
Haught, Derek
Corporate Director · Individual
Hawkins, John
Corporate Director · Individual
Jackman, Jason
Corporate Director · Individual
Knochelmann, Kris
Corporate Director · Individual
Koester, Joseph
Corporate Director · Individual
Ladenburger, Marsha
Corporate Director · Individual
Moorhead, Robert
Corporate Director · Individual
Neff, Judith
Operational/Managerial Control · Individual
Nelson, Kristi
Corporate Director · Individual
Price, Donald
Corporate Director · Individual
Ritchey-Baldwin, Lori
Corporate Officer · Individual
Schaeffer, Andrew
Corporate Director · Individual
Schroer, Jeanne
Corporate Director · Individual
Stevens, Robert
Corporate Director · Individual
Sweeney, Jackie
Corporate Director · Individual
Thompson, Amy
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Emerald Trace
Elsmere, KY
2-star overall rating with 2-star inspections with $9,318 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Village Care Center
Erlanger, KY
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Woodcrest Nursing and Rehabilitation Center
Elsmere, KY
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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