Cycle 1
Health 2024-11-26 · Fire 2024-11-26
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Lexington, KY
Mayfair Manor
1-star overall rating with 1-star inspections with abuse icon flag with $33,602 in total fines with 5 recent health deficiencies
3300 Tates Creek Road, Lexington, KY
(859) 266-2126
Overall
1 / 5
CMS overall stars
Health inspections
1 / 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
98
Certified beds
Average residents
83
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Signature Healthcare
Operator or chain grouping
Approved since
1977-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
71 facilities
Chain averages 3 overall / 3 health / 3 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
0.36
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
1.26
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.08
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
3.70
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.62
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.19
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.36
CMS adjusted RN staffing hours
Adjusted total hours
3.69
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
62%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,263
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.47
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.21% · Performance 22.33% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.94% · Performance 7.89% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.68
Baseline 75.79% · Performance 49.41% · Measure score 4.68 · Achievement 3.49 · Improvement 4.68
Adjusted total nurse staffing
2.31
Baseline 3.24 hours · Performance 3.74 hours · Measure score 2.31 · Achievement 2.31 · Improvement 1.44
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 14.23% |
10.72%
3.5 pts worse
|
Worse than the National Rate · Eligible stays 193 · Observed rate 19.69% · Lower 95% interval 10.96% |
| Discharge to community | 54.4% |
50.57%
3.8 pts better
|
No Different than the National Rate · Eligible stays 195 · Observed rate 43.59% · Lower 95% interval 47.45% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.66% |
95.27%
2.4 pts better
|
Numerator 125 · Denominator 128 |
| Falls with major injury | 0.78% |
0.77%
About the same
|
Numerator 1 · Denominator 128 |
| Discharge self-care score | 59.74% |
53.69%
6.1 pts better
|
Numerator 46 · Denominator 77 |
| Discharge mobility score | 22.08% |
50.94%
28.9 pts worse
|
Numerator 17 · Denominator 77 |
| Pressure ulcers or injuries, new or worsened | 4.69% |
2.29%
2.4 pts worse
|
Numerator 6 · Denominator 128 · Adjusted rate 4.24% |
| Healthcare-associated infections requiring hospitalization | 7.89% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 130 · Observed rate 10% · Lower 95% interval 5.52% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 98 |
| Staff flu vaccination coverage | 13.92% |
42%
28.1 pts worse
|
Numerator 22 · Denominator 158 |
| Discharge function score | 50.65% |
56.45%
5.8 pts worse
|
Numerator 39 · Denominator 77 |
| Transfer of health information to provider | 92.11% |
95.95%
3.8 pts worse
|
Numerator 70 · Denominator 76 |
| Transfer of health information to patient | 93.94% |
96.28%
2.3 pts worse
|
Numerator 31 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 15.15% |
25.2%
10 pts worse
|
Numerator 10 · Denominator 66 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.9
0.3 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.8 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.2
1 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 50.0% |
94.3%
44.3 pts worse
|
93.4%
43.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 49.2% · Q2 45.8% · Q3 33.3% · Q4 70.7% · 4Q avg 50.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 82.5% |
96.2%
13.7 pts worse
|
95.5%
13 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 82.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
3.8%
0.5 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.4% · Q3 3.7% · Q4 10.3% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.2% |
15.2%
7 pts better
|
11.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 15.1% · Q3 2.1% · Q4 3.9% · 4Q avg 8.2% |
| Percentage of long-stay residents who lose too much weight | 6.1% |
6.7%
0.6 pts better
|
5.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 8.2% · Q3 4.3% · Q4 8.2% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.9% |
29.6%
4.7 pts better
|
19.6%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.8% · Q2 25.0% · Q3 22.9% · Q4 30.0% · 4Q avg 24.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.5% |
17.6%
4.1 pts better
|
16.7%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 15.8% · Q3 7.9% · Q4 16.3% · 4Q avg 13.5% · 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 | 20.0% |
17.3%
2.7 pts worse
|
16.3%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.1% |
15.6%
1.5 pts better
|
14.9%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 22.4% · Q3 12.8% · Q4 14.9% · 4Q avg 14.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.7%
0.4 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · 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 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.8% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.2% |
19.8%
2.4 pts worse
|
19.8%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.2% · Q2 26.4% · Q3 15.7% · Q4 16.4% · 4Q avg 22.2% |
| Percentage of long-stay residents with pressure ulcers | 7.9% |
5.5%
2.4 pts worse
|
5.1%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 12.1% · Q3 6.4% · Q4 4.6% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.9% |
83.8%
3.9 pts worse
|
81.7%
1.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 77.9% · Q2 76.1% · Q3 81.0% · Q4 83.5% · 4Q avg 79.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.0% |
13.9%
6.1 pts worse
|
12.0%
8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.0% · Observed 20.6% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.8%
0.3 pts better
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 0.9% · Q4 2.6% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.1% |
83.6%
8.5 pts worse
|
79.7%
4.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.5% |
24.5%
3 pts worse
|
23.9%
3.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.5% · Observed 28.4% · Expected 24.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-06-24 · Fire 2021-06-24
15 health deficiencies
Top issue: Resident Rights (5 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2019-05-09 · Fire 2019-05-09
2 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2021-06-24
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2021-08-08
D · Potential for more than minimal harm
2021-06-24
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2021-08-08
D · Potential for more than minimal harm
2021-06-24
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2021-08-08
D · Potential for more than minimal harm
2021-06-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-08-08
D · Potential for more than minimal harm
2019-05-09
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2019-06-17
D · Potential for more than minimal harm
2019-05-09
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 2019-06-17
D · Potential for more than minimal harm
2019-05-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-06-17
Inspection history
Recent health citations
J · Immediate jeopardy
2024-11-26
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-08-23
E · Potential for more than minimal harm
2024-11-26
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-01-01
D · Potential for more than minimal harm
2024-11-26
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-01-01
D · Potential for more than minimal harm
2024-11-26
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-01-01
D · Potential for more than minimal harm
2024-11-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-01
J · Immediate jeopardy
2024-07-30
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-07-14
J · Immediate jeopardy
2024-07-30
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 2023-07-14
F · Potential for more than minimal harm
2024-07-30
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-08-24
F · Potential for more than minimal harm
2024-07-30
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-08-24
F · Potential for more than minimal harm
2024-07-30
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 2024-08-24
E · Potential for more than minimal harm
2024-07-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-24
D · Potential for more than minimal harm
2024-07-30
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2024-08-24
D · Potential for more than minimal harm
2024-07-30
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-08-24
D · Potential for more than minimal harm
2024-07-30
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-08-24
F · Potential for more than minimal harm
2021-06-24
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 2021-08-08
D · Potential for more than minimal harm
2021-06-24
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-08-08
D · Potential for more than minimal harm
2021-06-24
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2021-08-08
D · Potential for more than minimal harm
2021-06-24
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 2021-08-08
D · Potential for more than minimal harm
2021-06-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-08-08
D · Potential for more than minimal harm
2021-06-24
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 2021-08-08
D · Potential for more than minimal harm
2019-05-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-06-17
D · Potential for more than minimal harm
2019-05-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-06-17
Penalties and ownership
What sits behind the stars
$16,801
2024-11-26
Fine
Fine · fine $16,801
Fine
$6,500
2024-07-30
Fine
Fine · fine $6,500
Fine
$10,301
2024-07-30
Fine
Fine · fine $10,301
Fine
Ownership
Lp O Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Agemo Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Griffith, Heather
W-2 Managing Employee · Individual
Harrison, John
Corporate Officer · Individual
Jjla LLC
5% Or Greater Indirect Ownership Interest · Organization
Lpsnf Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Smedra, Ira
5% Or Greater Indirect Ownership Interest · Individual
Steier Iii, Elmer
5% Or Greater Indirect Ownership Interest · Individual
Wheaten LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
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Sayre Christian Village Nursing Home
Lexington, KY
2-star overall rating with 3-star inspections with $7,901 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Bluegrass Care & Rehabilitation Center
Lexington, KY
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
The Willows at Fritz Farm
Lexington, KY
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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