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
Chain footprint
2 facilities
Chain averages 3 overall / 3 health / 3 staffing / 3 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
0.31
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.35
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.42
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.07
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.17
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.27
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.31
CMS adjusted RN staffing hours
Adjusted total hours
3.45
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
63%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,190
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9826
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.57
Baseline 21.82% · Performance 20.82% · Measure score 1.57 · Achievement 1.31 · Improvement 1.57
Healthcare-associated infections
1.34
Baseline 7.51% · Performance 7.43% · Measure score 1.34 · Achievement 1.34 · Improvement 0
Total nurse turnover
3.35
Baseline 60.61% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 2.47
Adjusted total nurse staffing
2.21
Baseline 4.26 hours · Performance 3.71 hours · Measure score 2.21 · Achievement 2.21 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.91% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 142 · Observed rate 9.86% · Lower 95% interval 7.87% |
| Discharge to community | 59.32% |
50.57%
8.8 pts better
|
Better than the National Rate · Eligible stays 114 · Observed rate 52.63% · Lower 95% interval 50.94% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 84 · Denominator 84 |
| Falls with major injury | 3.57% |
0.77%
2.8 pts worse
|
Numerator 3 · Denominator 84 |
| Discharge self-care score | 44.29% |
53.69%
9.4 pts worse
|
Numerator 31 · Denominator 70 |
| Discharge mobility score | 32.86% |
50.94%
18.1 pts worse
|
Numerator 23 · Denominator 70 |
| Pressure ulcers or injuries, new or worsened | 3.57% |
2.29%
1.3 pts worse
|
Numerator 3 · Denominator 84 · Adjusted rate 3.04% |
| Healthcare-associated infections requiring hospitalization | 7.43% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 75 · Observed rate 6.67% · Lower 95% interval 4.2% |
| Staff COVID-19 vaccination coverage | 1.89% |
8.2%
6.3 pts worse
|
Numerator 2 · Denominator 106 |
| Staff flu vaccination coverage | 31.76% |
42%
10.2 pts worse
|
Numerator 54 · Denominator 170 |
| Discharge function score | 41.43% |
56.45%
15 pts worse
|
Numerator 29 · Denominator 70 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 71.79% |
96.28%
24.5 pts worse
|
Numerator 28 · Denominator 39 |
| Resident COVID-19 vaccinations up to date | 25.58% |
25.2%
0.4 pts better
|
Numerator 11 · Denominator 43 |
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 · Adjusted 1.1 · Observed 0.9 · Expected 1.6 · Used in QM five-star |
| 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 · Adjusted 1.0 · Observed 0.9 · Expected 1.4 · Used in QM five-star |
| 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 · Q1 91.4% · Q2 98.7% · Q3 98.6% · Q4 98.6% · 4Q avg 96.9% |
| 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 · 4Q avg 93.8% |
| 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 · Q1 4.3% · Q2 2.6% · Q3 2.7% · Q4 5.6% · 4Q avg 3.8% · Used in QM five-star |
| 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 · Q1 6.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% |
| 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 · Q1 3.6% · Q2 11.5% · Q3 10.8% · Q4 13.2% · 4Q avg 10.0% |
| 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 · Q1 11.9% · Q2 12.7% · Q3 12.3% · Q4 11.4% · 4Q avg 12.1% |
| 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 · Q1 4.0% · Q2 7.7% · Q3 5.8% · Q4 7.1% · 4Q avg 6.2% · 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 | 27.5% |
17.3%
10.2 pts worse
|
16.3%
11.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 27.5% · Used in QM five-star |
| 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 · Q1 26.1% · Q2 11.8% · Q3 12.7% · Q4 7.1% · 4Q avg 13.9% · Used in QM five-star |
| 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 · Q1 4.9% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 8.6% · 4Q avg 2.4% · Used in QM five-star |
| 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 · Q1 19.9% · Q2 19.2% · Q3 20.6% · Q4 22.1% · 4Q avg 20.5% |
| 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 · Q1 5.9% · Q2 5.5% · Q3 8.7% · Q4 2.5% · 4Q avg 5.7% · Used in QM five-star |
| 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 · Q1 96.2% · Q2 97.2% · Q3 98.5% · Q4 97.4% · 4Q avg 97.3% |
| 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 · Adjusted 15.9% · Observed 15.1% · Expected 10.6% · Used in QM five-star |
| 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 · Q1 2.9% · Q2 3.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| 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 · 4Q avg 83.3% |
| 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 · Adjusted 20.6% · Observed 18.9% · Expected 21.8% · Used in QM five-star |
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
Nearby options
Other facilities in reach
#1
Pine Meadows Post Acute
Lexington, KY
3-star overall rating with 3-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Homestead Post Acute
Lexington, KY
3-star overall rating with 3-star inspections with 3 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Cardinal Hill Skilled Rehabilitation Unit
Lexington, KY
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Jump out