Cycle 1
Health 2025-04-03 · Fire 2025-04-03
2 health deficiencies
Top issue: Infection Control (1 deficiency)
10 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Lexington, KY
Lexington Country Place
3-star overall rating with 3-star inspections with 2 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
700 Mason Headley Road, Lexington, KY
(859) 259-3486
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
111
Certified beds
Average residents
84
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Phoenix Senior Living
Operator or chain grouping
Approved since
1980-10-27
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.31
Registered nurse staffing
LPN hours / resident day
0.76
Licensed practical nurse staffing
Aide hours / resident day
2.35
Nurse aide staffing
Weekend hours
3.17
Weekend nurse staffing
RN turnover
63%
Annual RN turnover
Total nurse turnover
52%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.9
0.8 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
2.2
1.2 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
94.3%
2.6 pts better
|
93.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.8% |
96.2%
2.4 pts worse
|
95.5%
1.7 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
3.8%
About the same
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 1.5% |
15.2%
13.7 pts better
|
11.4%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 10.0% |
6.7%
3.3 pts worse
|
5.4%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.1% |
29.6%
17.5 pts better
|
19.6%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 6.2% |
17.6%
11.4 pts better
|
16.7%
10.5 pts better
|
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 | 27.5% |
17.3%
10.2 pts worse
|
16.3%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.9% |
15.6%
1.7 pts better
|
14.9%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
0.7%
1 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.4% |
1.7%
0.7 pts worse
|
1.7%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.5% |
19.8%
0.7 pts worse
|
19.8%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.7% |
5.5%
0.2 pts worse
|
5.1%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.3% |
83.8%
13.5 pts better
|
81.7%
15.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.9% |
13.9%
2 pts worse
|
12.0%
3.9 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.8%
0.2 pts better
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.3% |
83.6%
0.3 pts worse
|
79.7%
3.6 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.6% |
24.5%
3.9 pts better
|
23.9%
3.3 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-01-23 · Fire 2020-01-23
0 health deficiencies
No concentrated health issue counts in this cycle.
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-01-31 · Fire 2019-01-31
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-03
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2025-04-28
F · Potential for more than minimal harm
2025-04-03
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-05-16
F · Potential for more than minimal harm
2025-04-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-05-16
E · Potential for more than minimal harm
2025-04-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-16
E · Potential for more than minimal harm
2025-04-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-03
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-03
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-03
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-13
D · Potential for more than minimal harm
2025-04-03
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-05-16
D · Potential for more than minimal harm
2020-01-23
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 2020-02-17
D · Potential for more than minimal harm
2020-01-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-02-17
D · Potential for more than minimal harm
2020-01-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-02-17
D · Potential for more than minimal harm
2020-01-23
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2020-02-17
F · Potential for more than minimal harm
2019-01-31
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-03-29
E · Potential for more than minimal harm
2019-01-31
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2019-03-29
E · Potential for more than minimal harm
2019-01-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-03-29
D · Potential for more than minimal harm
2019-01-31
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2019-03-29
D · Potential for more than minimal harm
2019-01-31
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-03-29
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-03
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 2025-05-09
E · Potential for more than minimal harm
2025-04-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-09
F · Potential for more than minimal harm
2019-01-31
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 2019-03-29
E · Potential for more than minimal harm
2019-01-31
F761 · Pharmacy Service Deficiencies
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 2019-03-29
E · Potential for more than minimal harm
2019-01-31
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2019-03-29
D · Potential for more than minimal harm
2019-01-31
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 2019-03-29
D · Potential for more than minimal harm
2019-01-31
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2019-03-29
D · Potential for more than minimal harm
2019-01-31
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2019-03-29
D · Potential for more than minimal harm
2019-01-31
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 2019-03-29
D · Potential for more than minimal harm
2019-01-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-03-29
Penalties and ownership
What sits behind the stars
Ownership
Snh Proj Lincoln Trs LLC
5% Or Greater Direct Ownership Interest · Organization
Abp Trust
5% Or Greater Indirect Ownership Interest · Organization
Blackrock Inc
5% Or Greater Indirect Ownership Interest · Organization
Cheek, Allison
Operational/Managerial Control · Individual
Diversified Healthcare Trust
5% Or Greater Indirect Ownership Interest · Organization
Doodnauth, Davanand
Operational/Managerial Control · Individual
Flat Footed LLC
5% Or Greater Indirect Ownership Interest · Organization
H/2 Special Opportunities Iv L.p.
5% Or Greater Indirect Ownership Interest · Organization
Marinko, Jesse
Operational/Managerial Control · Individual
Pesek, Seth
Operational/Managerial Control · Individual
Phoenix Senior Living LLC
Operational/Managerial Control · Organization
Portnoy, Adam
5% Or Greater Indirect Ownership Interest · Individual
Portnoy, Adam
Corporate Director · Individual
Ramey, Courtney
Operational/Managerial Control · Individual
Silver Point Capital Offshore Fund
5% Or Greater Indirect Ownership Interest · Organization
Snh Trs Licensee Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Snh Trs, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Vanguard Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Whitt, Tina
Operational/Managerial Control · Individual
Wicks, Chasidy
Operational/Managerial Control · Individual
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#2
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#3
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