Louisville, KY
2-star overall rating with 1-star inspections with $16,724 in total fines with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
211 West Oak Street, Louisville, KY
(502) 589-3211
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
60
Certified beds
Average residents
48
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1984-07-11
CMS approved date
Coverage
Medicare + Medicaid
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
Staffing
RN hours / resident day
0.88
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.13
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.33
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
4.34
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
2.00
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.58
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.66
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
0.82
CMS adjusted RN staffing hours
Adjusted total hours
4.05
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Program rank
6,285
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.40
Composite VBP score used to determine payment impact.
Payment multiplier
0.9877
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
4.01
Baseline 21.57% · Performance 19.57% · Measure score 4.01 · Achievement 4.01 · Improvement 3.90
Healthcare-associated infections
2.69
Baseline 7.95% · Performance 7.03% · Measure score 2.69 · Achievement 2.69 · Improvement 2.61
Total nurse turnover
1.46
Baseline 64.18% · Performance 57.69% · Measure score 1.46 · Achievement 1.46 · Improvement 1.15
Adjusted total nurse staffing
5.19
Baseline 4.24 hours · Performance 4.56 hours · Measure score 5.19 · Achievement 5.19 · Improvement 1.57
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.51% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 76 · Observed rate 5.26% · Lower 95% interval 6.45% |
| Discharge to community | 61.95% |
50.57%
11.4 pts better
|
Better than the National Rate · Eligible stays 61 · Observed rate 60.66% · Lower 95% interval 53.7% |
| Medicare spending per beneficiary | 0.7 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 93.62% |
95.27%
1.6 pts worse
|
Numerator 44 · Denominator 47 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 47 |
| Discharge self-care score | 57.14% |
53.69%
3.5 pts better
|
Numerator 20 · Denominator 35 |
| Discharge mobility score | 20% |
50.94%
30.9 pts worse
|
Numerator 7 · Denominator 35 |
| Pressure ulcers or injuries, new or worsened | 4.26% |
2.29%
2 pts worse
|
Numerator 2 · Denominator 47 · Adjusted rate 5.09% |
| Healthcare-associated infections requiring hospitalization | 7.03% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 37 · Observed rate 5.41% · Lower 95% interval 3.77% |
| Staff COVID-19 vaccination coverage | 1.52% |
8.2%
6.7 pts worse
|
Numerator 1 · Denominator 66 |
| Staff flu vaccination coverage | 7.35% |
42%
34.6 pts worse
|
Numerator 5 · Denominator 68 |
| Discharge function score | 51.43% |
56.45%
5 pts worse
|
Numerator 18 · Denominator 35 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 42.86% |
25.2%
17.7 pts better
|
Numerator 12 · Denominator 28 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.9
0.6 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.2 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.2
1.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
94.3%
3.1 pts better
|
93.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.3% · Q2 91.9% · Q3 100.0% · Q4 100.0% · 4Q avg 97.4% |
| 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 2.7% · Q2 5.4% · Q3 2.4% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.9% |
15.2%
10.3 pts better
|
11.4%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 8.3% · Q3 2.7% · Q4 2.8% · 4Q avg 4.9% |
| Percentage of long-stay residents who lose too much weight | 6.3% |
6.7%
0.4 pts better
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 6.7% · Q3 2.9% · Q4 6.7% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.9% |
29.6%
12.7 pts better
|
19.6%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 19.4% · Q3 14.3% · Q4 16.1% · 4Q avg 16.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.7% |
17.6%
15.9 pts better
|
16.7%
15 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 0.0% · Q4 3.6% · 4Q avg 1.7% · 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 | 22.0% |
17.3%
4.7 pts worse
|
16.3%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.6% |
15.6%
5 pts better
|
14.9%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 10.3% · Q3 12.1% · Q4 16.7% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.7%
0.1 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
1.7%
0.3 pts worse
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.8% · Q3 2.5% · Q4 2.7% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.5% |
19.8%
6.3 pts better
|
19.8%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 26.2% · Q3 11.9% · Q4 7.9% · 4Q avg 13.5% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
5.5%
1.1 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 4.7% · Q3 6.4% · Q4 4.0% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.1% |
83.8%
3.3 pts better
|
81.7%
5.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 84.3% · Q2 81.1% · Q3 93.9% · Q4 90.3% · 4Q avg 87.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.5% |
13.9%
10.4 pts better
|
12.0%
8.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.5% · Observed 2.9% · Expected 9.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.8%
0.1 pts better
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.0% |
83.6%
8.6 pts worse
|
79.7%
4.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.0% |
24.5%
0.5 pts worse
|
23.9%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.0% · Observed 17.1% · Expected 16.3% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Administration (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-09-12
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-08-24
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 2025-08-24
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-08-24
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-08-24
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 2019-04-12
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-04-12
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-04-27
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-04-19
Inspection history
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-08-24
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-08-24
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-08-24
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-24
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-24
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-08-24
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-24
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-24
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-03-19
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 2021-08-12
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-08-12
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2021-08-12
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-07-28
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2021-08-12
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2021-08-12
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2021-07-28
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-08-12
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2021-08-12
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2021-08-12
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-08-12
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-08-12
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2021-08-12
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2021-08-12
Health
Provide and implement an infection prevention and control program.
Corrected 2021-08-12
Health
Provide and implement an infection prevention and control program.
Corrected 2019-03-31
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-04-10
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-04-23
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 2019-04-23
Penalties and ownership
Fine · fine $16,724
Fine
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
W-2 Managing Employee · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Nearby options
Louisville, KY
1-star overall rating with 2-star inspections with 6 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
Louisville, KY
1-star overall rating with 1-star inspections with Special Focus status with $306,141 in total fines with 23 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
Louisville, KY
2-star overall rating with 2-star inspections with $64,799 in total fines with 3 recent health deficiencies
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