Cycle 1
Health 2025-08-15 · Fire 2025-08-15
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Louisville, KY
The Episcopal Church Home
4-star overall rating with 3-star inspections with 1 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
7504 Westport Road, Louisville, KY
(502) 736-7800
Overall
4 / 5
CMS overall stars
Health inspections
3 / 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
26
Certified beds
Average residents
25
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Episcopal Retirement Homes, Inc.
Operator or chain grouping
Approved since
1991-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
3 facilities
Chain averages 5 overall / 4 health / 5 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
0.89
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.41
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
3.39
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
4.69
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
4.27
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.52
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
1.03
CMS adjusted RN staffing hours
Adjusted total hours
5.42
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 47% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 8 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 8.25% |
8.2%
0.1 pts better
|
Numerator 8 · Denominator 97 |
| Staff flu vaccination coverage | 90.1% |
42%
48.1 pts better
|
Numerator 91 · Denominator 101 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
94.3%
4.6 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · 4Q avg 98.9% |
| 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 | 8.0% |
3.8%
4.2 pts worse
|
3.3%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 4.3% · Q3 8.7% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.9% |
15.2%
5.3 pts better
|
11.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 14.3% · 4Q avg 9.9% |
| Percentage of long-stay residents who lose too much weight | 1.9% |
6.7%
4.8 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.4% |
29.6%
0.8 pts worse
|
19.6%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.6% |
17.6%
1 pts worse
|
16.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.6% · 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% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 29.6% |
17.3%
12.3 pts worse
|
16.3%
13.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 52.8% |
15.6%
37.2 pts worse
|
14.9%
37.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 52.8% · 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% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.7%
0.5 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.5% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.0% |
19.8%
13.2 pts worse
|
19.8%
13.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 51.7% · Q2 25.5% · Q3 20.4% · 4Q avg 33.0% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
5.5%
3.5 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.4% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.3% |
83.8%
0.5 pts worse
|
81.7%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 83.3% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-27 · Fire 2022-10-27
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-12-13 · Fire 2019-12-13
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-15
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2025-09-11
F · Potential for more than minimal harm
2025-08-15
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-09-11
F · Potential for more than minimal harm
2025-08-15
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-09-12
F · Potential for more than minimal harm
2025-08-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-11
F · Potential for more than minimal harm
2025-08-15
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-09-16
E · Potential for more than minimal harm
2025-08-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-09-11
F · Potential for more than minimal harm
2022-10-27
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-01-31
F · Potential for more than minimal harm
2022-10-27
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 2022-11-24
F · Potential for more than minimal harm
2022-10-27
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-03-01
F · Potential for more than minimal harm
2022-10-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-14
E · Potential for more than minimal harm
2022-10-27
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-12-04
E · Potential for more than minimal harm
2019-12-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-01-29
D · Potential for more than minimal harm
2019-12-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-12-13
D · Potential for more than minimal harm
2019-12-13
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2019-12-13
Inspection history
Recent health citations
J · Immediate jeopardy
2025-08-15
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.
Not marked corrected
D · Potential for more than minimal harm
2022-10-27
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 2022-12-01
D · Potential for more than minimal harm
2019-12-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-01-29
D · Potential for more than minimal harm
2019-12-13
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 2020-01-29
D · Potential for more than minimal harm
2019-12-13
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 2020-01-29
D · Potential for more than minimal harm
2019-12-13
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2020-01-29
D · Potential for more than minimal harm
2019-12-13
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 2020-01-29
Penalties and ownership
What sits behind the stars
Ownership
Episcopal Retirement Services
5% Or Greater Direct Ownership Interest · Organization
Episcopal Church Home Foundation Inc
5% Or Greater Direct Ownership Interest · Organization
Anim, Dora
Corporate Director · Individual
Coleman, Jomiya
Operational/Managerial Control · Individual
Coleman, Jomiya
W-2 Managing Employee · Individual
Cooper, W.
Corporate Director · Individual
Edwards, Beverly
Operational/Managerial Control · Individual
Edwards, Beverly
Corporate Officer · Individual
Edwards, Beverly
W-2 Managing Employee · Individual
Elin, Reverend Darren
Corporate Director · Individual
Episcopal Church Home Foundation Inc
Operational/Managerial Control · Organization
Episcopal Retirement Homes, Inc.
Operational/Managerial Control · Organization
Episcopal Retirement Services
Operational/Managerial Control · Organization
Fraser, Bonita
Operational/Managerial Control · Individual
Fraser, Bonita
W-2 Managing Employee · Individual
Fritschner, John
Corporate Director · Individual
Hagopian, Joann
Corporate Director · Individual
Hartman, Alan
Corporate Director · Individual
Hopkins, Gregory
Corporate Director · Individual
Kearney, Eric
Corporate Director · Individual
Koepke, John
Corporate Director · Individual
Lamb, Laura
Operational/Managerial Control · Individual
Lamb, Laura
Corporate Director · Individual
Lamb, Laura
Corporate Officer · Individual
Lamb, Laura
W-2 Managing Employee · Individual
Mcknight, Gerron
Corporate Director · Individual
Morton, Laura
Contracted Managing Employee · Individual
Payne, Jennifer
Corporate Director · Individual
Pope, Apryl
Corporate Director · Individual
Regan, Thomas
Corporate Director · Individual
Retford, David
Corporate Director · Individual
Smitherman, Albert
Corporate Director · Individual
Steward, Daniel
Operational/Managerial Control · Individual
Steward, Daniel
Corporate Officer · Individual
Steward, Daniel
W-2 Managing Employee · Individual
Woods, William
Corporate Director · Individual
Workman, David
Corporate Director · Individual
Zwilling, Elizabeth
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Signature Healthcare at Jefferson Manor Rehab & We
Louisville, KY
5-star overall rating with 4-star inspections with 1 recent health deficiencies
#2
Signature Healthcare at Jefferson Place Rehab & We
Louisville, KY
4-star overall rating with 3-star inspections with 1 recent health deficiencies
#3
Lyndon Crossing
Louisville, KY
0-star overall rating with 0-star inspections with Special Focus status with $20,563 in total fines with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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