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
Staffing
Hours and turnover
RN hours / resident day
0.36
Registered nurse staffing
LPN hours / resident day
1.26
Licensed practical nurse staffing
Aide hours / resident day
2.08
Nurse aide staffing
Weekend hours
3.13
Weekend nurse staffing
RN turnover
62%
Annual RN turnover
Total nurse turnover
39%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 | 20.0% |
17.3%
2.7 pts worse
|
16.3%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
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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
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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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