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
Staffing
Hours and turnover
RN hours / resident day
0.89
Registered nurse staffing
LPN hours / resident day
0.41
Licensed practical nurse staffing
Aide hours / resident day
3.39
Nurse aide staffing
Weekend hours
4.27
Weekend nurse staffing
RN turnover
43%
Annual RN turnover
Total nurse turnover
30%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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