Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cardinal Hill Skilled Rehabilitation Unit during CMS and state inspections, most recent first.
Food Not Stored or Measured Under Sanitary Conditions: Surveyors observed kitchen equipment stored turned up instead of properly positioned, uncovered utensils and sifters left out, and food items stored without labels or dates. A staff member also used the food thermometer incorrectly by inserting it through foil and a lid rather than into the food itself, and a cleaning cloth was left in the hand sink instead of being placed in the soiled barrel.
Infection control failed when staff did not wear gowns for EBP care, including wound care and toileting assistance, and when staff handled finger stick glucose testing with poor glucometer cleaning practices. Staff placed meters and supplies on unclean surfaces, kept strips in pockets, used wipes for too little time, and did not keep the meter wet for the required contact time. Interviews confirmed staff knew the expectations but did not consistently follow them.
A resident with multiple medical conditions and intact cognition reported missing money from his wallet to nursing staff. The incident was communicated to facility leadership, but the Administrator delayed reporting the allegation to state agencies beyond the required timeframe outlined in facility policy. Interviews indicated uncertainty among staff regarding the correct reporting procedures and timeframes.
A resident with anemia, CHF, and protein-calorie malnutrition, and with moderate cognitive impairment, refused the pneumococcal vaccine. The EHR had no documentation that the resident or representative received education on the benefits and potential side effects of the immunization, despite facility policy requiring it. The IP stated staff were checked for RSV, influenza, and Covid-19, but staff were not specifically trained to educate residents on vaccine benefits and risks.
Food Not Stored or Measured Under Sanitary Conditions
Penalty
Summary
The facility failed to prepare, store, and serve food under sanitary conditions. Review of the facility’s Food Storage policy showed that all food would be clearly labeled for identification, and review of USDA guidance on using a food thermometer showed the thermometer should be placed in the thickest part of the food, away from bone, fat, or gristle, or inserted through the side for thin foods. However, observations on 08/12/2025 found fry pans and pots turned up, an opened bin of scoops on the bottom shelf of the equipment stand turned up, and a large colander, mixing bowl, and steam table pan turned up on the bottom shelf in the production area. Two hand sifters were also opened on both ends and left uncovered under the production table. Additional observations showed commonly used food products stored with a clear-lid canister that had no date or label and other food products wrapped in plastic with no visible date or identification. A cleaning cloth was left in the hand sink behind the production area even though a soiled barrel was located nearby. During observation, a staff member opened the convection oven doors and pushed the thermometer through the foil on the pan, and later demonstrated taking food temperatures by placing the thermometer through the lid of macaroni and cheese. The Services Manager and General Manager of Food and Nutrition stated the facility expected equipment not to be turned up, foods to be labeled and dated, cleaning cloths to be properly stored or placed into the soiled barrel, and staff to use the food thermometer correctly.
Infection Control Failures With EBP PPE and Glucometer Disinfection
Penalty
Summary
The facility failed to maintain infection control for residents on Enhanced Barrier Precautions (EBP) and during glucometer use and disinfection. For wound care on a resident with a right foot wound, an RN removed the dressing and cleaned the wound while wearing gloves only and no gown. For another resident on EBP, a SRNA assisted the resident to the toilet and helped pull up the brief while wearing gloves only and no gown. The facility’s EBP procedure and the CDC EBP poster both required gloves and a gown for wound care and for changing briefs or assisting with toileting. The facility also failed to follow its glucometer cleaning and disinfection process during multiple finger stick blood sugar checks. A SRNA placed glucometer cases and meters on unclean surfaces such as a dirty linen cart, a bedside table, a chair, a cloth bag, and a rolling cart in resident rooms. The SRNA kept glucose strips in her pockets and carried wipes inside a glove in her pocket. During several checks, she wiped meters for only 10 to 30 seconds, then placed the used meter back into the case without fully covering it with the wipe. In one instance, she later moved the glucometer case and meter around the unit and then cleaned the meter at the nurse’s station. Another SRNA used a rolling cart with glucose supplies inside resident rooms and placed the glucometer on the cart or clipboard after checks. The facility’s policy required semi-critical equipment to be disinfected at the point of use immediately after each procedure, and the glucometer manufacturer’s instructions required cleaning and disinfecting the meter with the surface remaining damp for the full contact time. The purple top wipes had a two-minute contact time. Observations showed staff did not time the disinfecting process as directed, did not keep the meter wet for the full contact time, and did not consistently clean all surfaces of the glucometer. Interviews with staff and leadership confirmed staff had been trained on EBP and glucometer cleaning, but staff stated they forgot, felt nervous, or sometimes got lax, and the DON stated there was no regular audit to observe glucometer cleaning and disinfection.
Failure to Timely Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of a resident's property within the required timeframe. Specifically, a resident with diagnoses including atrial fibrillation, osteoarthritis, and congestive heart failure, who was assessed to have intact cognition, reported missing money from his wallet to a nurse. This report was communicated via email to the Director of Nursing (DON) and the Administrator. However, the Administrator did not notify the appropriate state agencies until two days after the initial report, exceeding the facility's policy requirement to report such incidents immediately and to notify state agencies within two hours. Interviews revealed that the DON was unaware of the specific reporting timeframe and was not involved in the on-call process, while the Administrator believed the reporting window was 24 to 48 hours and stated she reported the incident as soon as she was made aware. The facility's documentation did not mention the presence of money among the resident's belongings at admission. The resident later stated he did not recall the details but confirmed money was missing and that he had reported it to nursing staff, with no follow-up communication received.
Lack of Education for Pneumococcal Immunization Refusal
Penalty
Summary
The facility failed to provide education regarding the benefits and potential side effects of pneumococcal immunizations for 1 of 6 residents reviewed for pneumococcal vaccines, Resident 44. The facility policy titled, Influenza and Pneumococcal Immunization, last reviewed 12/19/2024, stated the resident's medical record should include documentation that each resident and/or the resident's representative received education regarding the benefits and potential side effects of the pneumococcal immunization. Resident 44 was admitted on 08/02/2025 with diagnoses including anemia, congestive heart failure, and protein-calorie malnutrition, and the admission MDS with an ARD of 08/09/2025 showed a BIMS score of 12 out of 15, indicating moderate cognitive impairment. The EHR showed the resident refused the pneumococcal vaccine, but there was no documentation that education about the benefits and potential side effects of the immunization was provided. During interview, the Infection Preventionist stated the facility checked residents for RSV, influenza, and Covid-19, but she did not specifically train staff to educate residents on the benefits and risks of the vaccines.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lexington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pine Meadows Post Acute | 0.4 mi | ★★★★★ | 6 | 0 |
| Homestead Post Acute | 0.5 mi | ★★★★★ | 0 | 0 |
| Cambridge Nursing & Rehabilitation Center | 0.5 mi | ★★★★★ | 6 | 0 |
| Lexington Country Place | 1.1 mi | ★★★★★ | 0 | 0 |
| The Willows At Citation | 4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.