Cycle 1
Health 2025-05-14 · Fire 2025-05-14
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Louisville, KY
Valhalla Post Acute
2-star overall rating with 1-star inspections with $17,963 in total fines with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
300 Shelby Station Drive, Louisville, KY
(502) 254-0009
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
162
Certified beds
Average residents
155
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
2004-09-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 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
0.60
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.34
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.83
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.57
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
2.84
CMS adjusted total nurse staffing hours
Case-mix index
1.84
Higher values indicate more complex resident acuity
RN turnover
68%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
76%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,722
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0.13
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.04% · Performance 24.77% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.27% · Performance 7.81% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0.05
Baseline 74.15% · Performance 71.43% · Measure score 0.05 · Achievement 0 · Improvement 0.05
Adjusted total nurse staffing
0
Baseline 3.89 hours · Performance 3.20 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.17% |
10.72%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 331 · Observed rate 13.9% · Lower 95% interval 10.63% |
| Discharge to community | 63.66% |
50.57%
13.1 pts better
|
Better than the National Rate · Eligible stays 279 · Observed rate 62.37% · Lower 95% interval 58.24% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.44% |
95.27%
4.2 pts better
|
Numerator 178 · Denominator 179 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 179 |
| Discharge self-care score | 45.74% |
53.69%
7.9 pts worse
|
Numerator 43 · Denominator 94 |
| Discharge mobility score | 37.23% |
50.94%
13.7 pts worse
|
Numerator 35 · Denominator 94 |
| Pressure ulcers or injuries, new or worsened | 1.68% |
2.29%
0.6 pts better
|
Numerator 3 · Denominator 179 · Adjusted rate 2.06% |
| Healthcare-associated infections requiring hospitalization | 7.81% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 189 · Observed rate 7.41% · Lower 95% interval 5.25% |
| Staff COVID-19 vaccination coverage | 1.39% |
8.2%
6.8 pts worse
|
Numerator 3 · Denominator 216 |
| Staff flu vaccination coverage | 97.09% |
42%
55.1 pts better
|
Numerator 200 · Denominator 206 |
| Discharge function score | 67.02% |
56.45%
10.6 pts better
|
Numerator 63 · Denominator 94 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 53 · Denominator 53 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 75 · Denominator 75 |
| Resident COVID-19 vaccinations up to date | 8.7% |
25.2%
16.5 pts worse
|
Numerator 8 · Denominator 92 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.9
0.4 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 3.0 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
2.2
0.4 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 3.0 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
94.3%
5.5 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.2% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.9% |
96.2%
0.7 pts better
|
95.5%
1.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
3.8%
2.5 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.7% · Q3 0.9% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 96.0% |
15.2%
80.8 pts worse
|
11.4%
84.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.5% · Q2 95.3% · Q3 98.0% · Q4 97.3% · 4Q avg 96.0% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
6.7%
2.7 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 2.8% · Q3 6.7% · Q4 5.6% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.6% |
29.6%
7 pts better
|
19.6%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 20.4% · Q3 26.6% · Q4 22.0% · 4Q avg 22.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.3% |
17.6%
8.3 pts better
|
16.7%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 7.1% · Q3 9.7% · Q4 10.0% · 4Q avg 9.3% · 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 | 8.6% |
17.3%
8.7 pts better
|
16.3%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q2 12.2% · Q3 4.8% · Q4 4.5% · 4Q avg 8.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.2% |
15.6%
6.4 pts better
|
14.9%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 10.7% · Q3 14.0% · Q4 3.0% · 4Q avg 9.2% · 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 | 0.4% |
1.7%
1.3 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.8% |
19.8%
6 pts better
|
19.8%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.1% · Q2 10.2% · Q3 11.1% · Q4 8.7% · 4Q avg 13.8% |
| Percentage of long-stay residents with pressure ulcers | 3.1% |
5.5%
2.4 pts better
|
5.1%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 4.4% · Q3 2.6% · Q4 2.7% · 4Q avg 3.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.0% |
83.8%
10.2 pts better
|
81.7%
12.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 88.8% · Q3 92.5% · Q4 98.1% · 4Q avg 94.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.3% |
13.9%
2.4 pts worse
|
12.0%
4.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.3% · Observed 15.4% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.8%
0.4 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 1.6% · Q3 0.8% · Q4 0.8% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.9% |
83.6%
7.3 pts better
|
79.7%
11.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.1% |
24.5%
0.6 pts worse
|
23.9%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.1% · Observed 24.2% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-06 · Fire 2024-02-06
9 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2020-01-31 · Fire 2020-01-31
8 health deficiencies
Top issue: Administration (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-06-05
F · Potential for more than minimal harm
2025-05-14
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-06-05
F · Potential for more than minimal harm
2025-05-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-01
F · Potential for more than minimal harm
2025-05-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-05
D · Potential for more than minimal harm
2025-05-14
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 2025-07-01
D · Potential for more than minimal harm
2025-05-14
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-06-16
D · Potential for more than minimal harm
2025-05-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-06-16
F · Potential for more than minimal harm
2024-04-17
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-05-05
F · Potential for more than minimal harm
2024-02-06
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-03-02
F · Potential for more than minimal harm
2024-02-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-01
F · Potential for more than minimal harm
2024-02-06
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-03-01
F · Potential for more than minimal harm
2024-02-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-05-04
F · Potential for more than minimal harm
2024-02-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-05
F · Potential for more than minimal harm
2024-02-06
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-05-05
F · Potential for more than minimal harm
2024-02-06
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-03-09
F · Potential for more than minimal harm
2024-02-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-09
E · Potential for more than minimal harm
2024-02-06
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 2024-03-02
E · Potential for more than minimal harm
2024-02-06
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-04-01
E · Potential for more than minimal harm
2024-02-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-05-05
E · Potential for more than minimal harm
2024-02-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-02
D · Potential for more than minimal harm
2024-02-06
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-06
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-03-06
F · Potential for more than minimal harm
2020-01-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-03-10
F · Potential for more than minimal harm
2020-01-31
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-03-10
F · Potential for more than minimal harm
2020-01-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-03-10
D · Potential for more than minimal harm
2020-01-31
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 2020-03-10
D · Potential for more than minimal harm
2020-01-31
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2020-03-10
D · Potential for more than minimal harm
2020-01-31
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-03-10
D · Potential for more than minimal harm
2020-01-31
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-03-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-08
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2025-08-15
F · Potential for more than minimal harm
2025-05-14
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 2025-08-15
D · Potential for more than minimal harm
2025-05-14
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-08-08
J · Immediate jeopardy
2024-05-17
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 2024-05-06
E · Potential for more than minimal harm
2024-04-20
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 2024-05-06
J · Immediate jeopardy
2024-02-06
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 2022-01-01
J · Immediate jeopardy
2024-02-06
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2022-01-01
J · Immediate jeopardy
2024-02-06
F837 · Administration Deficiencies
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2022-01-01
F · Potential for more than minimal harm
2024-02-06
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 2024-03-01
F · Potential for more than minimal harm
2024-02-06
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-03-01
E · Potential for more than minimal harm
2024-02-06
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-06
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-06
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-06
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-03-01
D · Potential for more than minimal harm
2024-02-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-01
F · Potential for more than minimal harm
2020-01-31
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 2020-03-10
D · Potential for more than minimal harm
2020-01-31
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-03-10
D · Potential for more than minimal harm
2020-01-31
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2020-03-10
D · Potential for more than minimal harm
2020-01-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-03-10
Penalties and ownership
What sits behind the stars
$5,909
2024-02-06
Fine
Fine · fine $5,909
Fine
$12,054
2024-02-06
Fine
Fine · fine $12,054
Fine
Ownership
Providence Group Inc
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Corporate Officer · Individual
Babar, Muhammad
Contracted Managing Employee · Individual
Estes, Taylor
W-2 Managing Employee · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Forest Springs Health Campus
Louisville, KY
5-star overall rating with 5-star inspections
#2
Jeffersontown Rehabilitation
Jeffersontown, KY
2-star overall rating with 2-star inspections with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Signature Healthcare of East Louisville
Louisville, KY
1-star overall rating with 1-star inspections with $10,364 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Jump out