Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
The Episcopal Church Home
Louisville, KY · 26 certified beds · Last Life Safety survey August 15, 2025
CMS Certification Number 185310 · first certified October 1991
Ownership
Operated by EPISCOPAL RETIREMENT HOMES, INC. · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within KY
14 citations — more than 77% of the 267 certified nursing homes in KY. Compared within KY rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 6 citations; the earlier surveys in the window averaged 4. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens October 2026. This facility’s last Life Safety survey was August 2025. Facilities in KY are typically surveyed 14–59 months after the last one (median 28), measured over 391 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
2 of the 14 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 14 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
How that compares
Compared with the median facility in KY, and nationally. Surveyors differ markedly between states, so the KY figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 14 |
| Median facility in KY | 7 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| December 13, 2019 | 3 |
| October 27, 2022 | 5 |
| August 15, 2025 | 6 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2025-08-15 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 1 | 2022-10-27 |
| K-0919 | Meet requirements for the use of electrical equipment. | 1 | 2019-12-13 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2025-08-15 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 1 | 2025-08-15 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2022-10-27 |
| K-0293 | Have properly located and lighted "Exit" signs. | 1 | 2025-08-15 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 1 | 2025-08-15 |
What the citations cover
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Smoke Deficiencies 4
- Emergency Preparedness Deficiencies 2
- Egress Deficiencies 2
- Other 2
| Category | Citations |
|---|---|
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Smoke Deficiencies | 4 |
| Emergency Preparedness Deficiencies | 2 |
| Egress Deficiencies | 2 |
| Construction Deficiencies | 1 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 15, 2025 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (September 11, 2025) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (September 11, 2025) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (September 12, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (September 11, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 11, 2025) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (September 16, 2025) |
October 27, 2022 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | Deficient, Provider has date of correction (January 31, 2023) |
| K-0222 | 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. | Deficient, Provider has date of correction (November 24, 2022) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (March 1, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 14, 2023) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (December 4, 2022) |
December 13, 2019 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (January 29, 2020) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 13, 2019) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (December 13, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.