Cycle 1
Health 2025-04-24 · Fire 2025-04-24
3 health deficiencies
Top issue: Administration (1 deficiency)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Lexington, KY
Sayre Christian Village Nursing Home
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
3775 Belleau Wood Drive, Lexington, KY
(859) 271-9000
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
164
Certified beds
Average residents
158
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1991-03-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.65
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.81 · national 0.87
Aide hours / resident day
2.60
Nurse aide staffing · state 2.43 · national 2.35
Total nurse hours
4.16
All reported nurse hours · state 4.01 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.58 · national 1.54
Weekend hours
3.87
Weekend nurse staffing · state 3.50 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.52 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.70
CMS adjusted RN staffing hours
Adjusted total hours
4.48
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
42%
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
11,093
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.05
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.66% · Performance 21.86% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.19% · Performance 7.90% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.35
Baseline 52.38% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 0.36
Adjusted total nurse staffing
3.87
Baseline 3.49 hours · Performance 4.18 hours · Measure score 3.87 · Achievement 3.87 · Improvement 2.52
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.54% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 163 · Observed rate 11.66% · Lower 95% interval 8.18% |
| Discharge to community | 31.14% |
50.57%
19.4 pts worse
|
Worse than the National Rate · Eligible stays 112 · Observed rate 23.21% · Lower 95% interval 22.34% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 88% |
95.27%
7.3 pts worse
|
Numerator 88 · Denominator 100 |
| Falls with major injury | 1% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 100 |
| Discharge self-care score | 27.45% |
53.69%
26.2 pts worse
|
Numerator 14 · Denominator 51 |
| Discharge mobility score | 29.41% |
50.94%
21.5 pts worse
|
Numerator 15 · Denominator 51 |
| Pressure ulcers or injuries, new or worsened | 6% |
2.29%
3.7 pts worse
|
Numerator 6 · Denominator 100 · Adjusted rate 5.06% |
| Healthcare-associated infections requiring hospitalization | 7.9% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 79 · Observed rate 8.86% · Lower 95% interval 5% |
| Staff COVID-19 vaccination coverage | 9.62% |
8.2%
1.4 pts better
|
Numerator 20 · Denominator 208 |
| Staff flu vaccination coverage | 9.05% |
42%
33 pts worse
|
Numerator 18 · Denominator 199 |
| Discharge function score | 31.37% |
56.45%
25.1 pts worse
|
Numerator 16 · Denominator 51 |
| Transfer of health information to provider | 93.55% |
95.95%
2.4 pts worse
|
Numerator 29 · Denominator 31 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 30.19% |
25.2%
5 pts better
|
Numerator 16 · Denominator 53 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.9
0.6 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.2 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
2.2
0.2 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.2 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 86.8% |
94.3%
7.5 pts worse
|
93.4%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 89.4% · Q2 92.9% · Q3 87.7% · Q4 77.6% · 4Q avg 86.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.6% |
96.2%
4.6 pts worse
|
95.5%
3.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.8%
1.2 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 5.7% · Q3 4.3% · Q4 3.4% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
15.2%
15.2 pts better
|
11.4%
11.4 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 who lose too much weight | 11.4% |
6.7%
4.7 pts worse
|
5.4%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 16.5% · Q3 9.4% · Q4 9.7% · 4Q avg 11.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.1% |
29.6%
4.5 pts better
|
19.6%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 28.4% · Q3 22.1% · Q4 25.7% · 4Q avg 25.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.7% |
17.6%
1.1 pts worse
|
16.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.7% · Q2 15.2% · Q3 20.2% · Q4 18.3% · 4Q avg 18.7% · 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 | 12.7% |
17.3%
4.6 pts better
|
16.3%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 6.8% · Q3 9.8% · Q4 16.2% · 4Q avg 12.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.7% |
15.6%
5.9 pts better
|
14.9%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 8.8% · Q3 6.0% · Q4 13.5% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.9% |
1.7%
0.8 pts better
|
1.7%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.0% · Q3 1.5% · Q4 1.4% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.4% |
19.8%
10.6 pts worse
|
19.8%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 29.9% · Q3 35.0% · Q4 30.9% · 4Q avg 30.4% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
5.5%
1 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 5.1% · Q3 2.7% · Q4 3.5% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 71.8% |
83.8%
12 pts worse
|
81.7%
9.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 85.5% · Q2 85.4% · Q3 61.2% · Q4 55.1% · 4Q avg 71.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.3% |
13.9%
3.4 pts worse
|
12.0%
5.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.3% · Observed 15.7% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 7.9% |
1.8%
6.1 pts worse
|
1.6%
6.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 9.1% · Q3 9.3% · Q4 7.5% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 69.6% |
83.6%
14 pts worse
|
79.7%
10.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 69.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 33.4% |
24.5%
8.9 pts worse
|
23.9%
9.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 33.4% · Observed 31.5% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-02-06 · Fire 2020-02-06
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
6 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Cycle 3
Health 2019-02-14 · Fire 2019-02-14
15 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-04-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-15
E · Potential for more than minimal harm
2025-04-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-24
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2025-05-15
D · Potential for more than minimal harm
2025-04-24
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-05-15
E · Potential for more than minimal harm
2020-02-06
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-02-26
E · Potential for more than minimal harm
2020-02-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-02-26
D · Potential for more than minimal harm
2020-02-06
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 2020-02-26
D · Potential for more than minimal harm
2020-02-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-02-26
D · Potential for more than minimal harm
2020-02-06
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2020-02-26
D · Potential for more than minimal harm
2020-02-06
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2020-02-26
F · Potential for more than minimal harm
2019-02-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-03-31
F · Potential for more than minimal harm
2019-02-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-03-31
E · Potential for more than minimal harm
2019-02-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-03-31
D · Potential for more than minimal harm
2019-02-14
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 2019-04-05
D · Potential for more than minimal harm
2019-02-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-03-31
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-04-24
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2025-05-19
E · Potential for more than minimal harm
2025-04-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-19
D · Potential for more than minimal harm
2025-04-24
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-05-19
G · Actual harm
2023-11-09
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 2023-12-08
G · Actual harm
2023-11-09
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 2023-12-08
D · Potential for more than minimal harm
2023-11-09
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-09
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-12-08
E · Potential for more than minimal harm
2020-02-06
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 2020-02-26
D · Potential for more than minimal harm
2020-02-06
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 2020-02-26
E · Potential for more than minimal harm
2019-02-14
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 2019-03-31
E · Potential for more than minimal harm
2019-02-14
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 2019-03-31
E · Potential for more than minimal harm
2019-02-14
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2019-03-31
D · Potential for more than minimal harm
2019-02-14
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2019-03-31
D · Potential for more than minimal harm
2019-02-14
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 2019-03-31
D · Potential for more than minimal harm
2019-02-14
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-03-31
D · Potential for more than minimal harm
2019-02-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-03-31
D · Potential for more than minimal harm
2019-02-14
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2019-03-31
D · Potential for more than minimal harm
2019-02-14
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-03-31
D · Potential for more than minimal harm
2019-02-14
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 2019-03-31
D · Potential for more than minimal harm
2019-02-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-03-31
Penalties and ownership
What sits behind the stars
$3,950
2023-11-09
Fine
Fine · fine $3,950
Fine
$3,951
2023-11-09
Fine
Fine · fine $3,951
Fine
Ownership
Buckley, Benjamin
Corporate Director · Individual
Christian Benevolent Outreach, Inc.
Operational/Managerial Control · Organization
Dundon, John
Corporate Officer · Individual
Dundon, John
W-2 Managing Employee · Individual
Herndon, Darlene
Corporate Director · Individual
Keinath, Kennetha
Corporate Director · Individual
Ring, Ron
Corporate Director · Individual
Upton, Penny
Corporate Officer · Individual
Venis, Karen
Corporate Officer · Individual
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