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
Staffing
Hours and turnover
RN hours / resident day
0.65
Registered nurse staffing
LPN hours / resident day
0.91
Licensed practical nurse staffing
Aide hours / resident day
2.60
Nurse aide staffing
Weekend hours
3.87
Weekend nurse staffing
RN turnover
42%
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 | 2.5 |
1.9
0.6 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 | 12.7% |
17.3%
4.6 pts better
|
16.3%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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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