Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lexington Country Place during CMS and state inspections, most recent first.
A resident with Parkinson’s disease, repeated falls, and moderate cognitive impairment fell and then developed worsening pain, swelling, and inability to bear weight. Staff documented an initial call to the physician’s office, but there was no timely follow-up or continued notification when the resident’s condition declined. The physician later stated he was not informed of the fall or the severity of the resident’s pain and swelling until a text message was sent, and the resident was subsequently found to have a femur fracture.
A resident with Parkinson’s disease, moderate cognitive impairment, and a history of repeated falls sustained multiple falls in the room while trying to toilet, reach items, or self-ambulate. After one fall, nursing documentation was incomplete and the resident developed worsening pain, swelling, and inability to bear weight before a femur fracture was identified and the resident was transferred to the hospital. Falls continued after surgery, and observations showed the resident in bed with the alarm not sounding, items out of reach, and the room cluttered.
Delayed post-fall assessment and fracture identification A resident with Parkinson’s disease, repeated falls, and cognitive impairment fell in her room and reported right leg pain, but nursing staff did not complete a thorough post-fall assessment or clearly document key findings such as swelling, deformity, or motor response. The resident’s pain and condition worsened, with bed-bound status, refusal of meals, swelling, and inability to bear weight, yet physician notification and diagnostic imaging were delayed. The fracture was not identified until later imaging showed a distal femur fracture and a greater trochanter fracture, and the resident was then transferred to the hospital.
A facility failed to maintain a clean, tidy, and homelike environment for multiple residents. Surveyors observed trash, debris, used gloves, used mouth swabs, and a contaminated dressing on floors and bedside tables, along with debris buildup around baseboards and privacy curtains in disrepair. One resident's bed linens were visibly soiled with stains, crumbs, and what appeared to be fecal smearing, while residents and staff stated rooms were not always cleaned daily and weekend staffing was reduced.
Failure to Provide Written Transfer and Bed Hold Notices: The facility did not provide written transfer notices to the representatives of two residents who were sent to the ED by EMS after acute events. One resident had Parkinson’s disease, repeated falls, and moderate cognitive impairment after a fractured femur was identified; the other had Alzheimer’s disease, dementia, anxiety, and severe cognitive impairment after a fall. Records contained no transfer or bed hold documentation, and staff could not confirm that the required written notices were mailed to the representatives.
Failure to keep a resident’s urinary catheter drainage bag covered with a dignity cover. A resident with aphasia, moderate cognitive impairment, and an indwelling urinary catheter had the drainage bag left visible from the hallway and outside the room on multiple observations. Staff and leadership stated catheter drainage bags were expected to remain covered to protect privacy and dignity, but the care plan did not include interventions related to any refusal of the cover.
Failure to Follow Hand Hygiene and EBP PPE Requirements: An LPN exited a resident’s room wearing gloves, touched the medication cart and a cup with the contaminated gloves, and re-entered the room without removing the gloves or performing hand hygiene. On another observation, a UM provided oral care and handled the resident’s G-tube without the required gown while the resident was on EBP; an enteral syringe with pink liquid was also present on the overbed table. The resident had a G-tube, urinary catheter, wound, and moderate cognitive impairment.
Surveyors found that food service staff failed to follow sanitary procedures, including stacking wet dome lids, taking food temperatures incorrectly through plastic wrap, and not consistently practicing proper hand hygiene when changing gloves or tasks. These actions did not align with facility procedures or USDA guidelines, and staff interviews confirmed lapses in following required food safety practices.
Several residents with wounds or indwelling devices had active orders for Enhanced Barrier Precautions (EBP), but required EBP signage was not posted outside their rooms. Staff interviews confirmed reliance on signage to determine appropriate PPE, and facility policy expected immediate signage placement after EBP orders. The absence of signage led to a breakdown in communication of infection control requirements for staff and visitors.
Delayed Physician Notification After Resident Fall and Change in Condition
Penalty
Summary
The facility failed to promptly notify the physician after a resident fell and then showed a significant change in condition. The resident had diagnoses including Parkinson’s disease with dyskinesia, repeated falls, and cognitive communication deficit, and a quarterly MDS showed a BIMS score of 11 out of 15, indicating moderate cognitive impairment. After the fall, staff documented pain in the right knee, later increased pain, swelling, inability to bear weight, and a change in mobility and functioning, but the physician was not promptly informed of these changes. Record review showed the resident was found on the floor in her room after reaching for personal items. A fall report documented the resident was alert, had pain rated 5 out of 10, and no visible injury was observed. Nursing documentation indicated an attempt to call the physician’s office, but there was no documentation of continued attempts or timely follow-up until a later text message was sent the next day. The physician stated he first learned of the fall through a text message from staff and was not told about the resident’s pain, swelling, or decreased range of motion. The resident’s condition worsened over the next two days. Staff documented that she was bed bound, refused meals, had increased pain rated 8 out of 10, swelling of the right knee, and could not bear weight on the right knee and hip. Another nursing note described the resident crying in pain with severe leg pain, but there was no documentation that the physician was notified at that time. A radiology report later identified a fracture of the distal femoral shaft with malalignment and soft tissue swelling. Interviews with the DON, administrator, physician, and staff confirmed that the physician was not contacted in a timely manner and that staff did not continue attempts to reach him after the initial unsuccessful call.
Inadequate Supervision and Repeated Falls
Penalty
Summary
The facility failed to ensure adequate supervision and failed to keep a resident free from falls. The resident had diagnoses including Parkinson’s disease with dyskinesia, repeated falls, and cognitive communication deficit, and the quarterly MDS showed a BIMS score of 9 out of 15, indicating moderate cognitive impairment. The care plan identified fall risk related to decreased mobility, Parkinson’s disease, weakness, psychotropic medication use, and opioid medication use, with interventions such as encouraging the resident to remain in the day area for supervision, anticipating needs, offering toileting, and monitoring during rounds. Record review showed the resident sustained 10 falls between 12/29/2025 and 04/25/2026, including falls in the resident’s room while attempting toileting, self-ambulating, or reaching for personal items. On 03/08/2026, the resident fell in the room after attempting to reach personal items and later reported right knee pain rated 5 out of 10. Nursing documentation and neurological assessment were incomplete, including missing motor response documentation for the right lower extremity. The resident’s condition worsened over the next day, with increased pain, swelling, inability to bear weight, and tears while reporting severe leg pain. The resident was later found to have a fracture of the right distal femoral shaft with malalignment and a nondisplaced fracture of the right greater trochanter, and was transferred to the hospital where a closed fracture of the right femur and head injury were diagnosed. The report also described delays in physician notification after the fall, with staff unable to reach the physician initially and no timely escalation documented. After hospitalization and surgical repair, the resident continued to fall in the facility, including sliding from bed, turning off alarms, and falling while trying to retrieve items or toilet. Observations also showed the resident in bed with the alarm not sounding, the bedside table out of reach, and the room cluttered, while the resident stated she was trying to reach items and needed to get out of bed.
Delayed post-fall assessment and fracture identification
Penalty
Summary
The facility failed to ensure appropriate treatment and care were provided after a resident with Parkinson’s disease, repeated falls, cognitive communication deficit, and moderate cognitive impairment fell in her room. After the fall, nursing documentation showed the resident was alert and reported pain in the right knee or leg, but the assessments did not document a thorough evaluation of the injured extremity, including bruising, swelling, shortening, rotation, deformity, or motor response. The resident was also not promptly evaluated by the physician after the initial fall, and the facility did not have a defined process for continued physician notification when the first attempt was unsuccessful. Following the fall, staff documented the resident as having pain rated 5/10, but the pain assessment was not consistently completed using a tool appropriate for her cognitive status. The resident’s condition changed over the next day, with documentation showing she became bed-bound, refused meals, had increased pain, and developed swelling in the right knee with inability to bear weight on the right knee and hip. Despite these changes, the physician was not contacted immediately after the fall, and the x-ray was not obtained until the following day after the family requested imaging. The facility’s documentation also showed gaps in the communication with the physician, including a text message that only stated the family wanted an x-ray and did not describe the severity of the resident’s condition. The delayed assessment and delayed diagnostic testing resulted in late identification of a right distal femoral shaft fracture with malalignment and a nondisplaced fracture of the right greater trochanter. The resident was later transferred to the hospital, where exam findings included shortening and external rotation of the right lower extremity, painful and restricted hip movement, and tenderness over the distal femur. Interviews with staff and family confirmed the resident had significant pain and functional decline after the fall, while nursing staff acknowledged they did not promptly escalate the situation or clearly document the resident’s condition and the urgency of the change in status.
Unsafe and Unclean Resident Rooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for 5 of 25 sampled residents, including R6, R13, R14, R26, and R93. Observations on 04/27/2026 and 04/28/2026 found five resident rooms with privacy curtains in disrepair. Surveyors also observed trash on bedside tables and floors, including used mouth swabs and a contaminated dressing with gloves, debris accumulation around baseboards, and soiled bed linens on a bed. The facility policy titled Resident's Rights stated residents had the right to be treated with consideration, respect, and recognition of dignity and individuality, and the Cleaning and Disinfecting policy stated housekeeping staff cleaned floors and tabletops regularly, when spills occurred, and when surfaces were visibly soiled. In R14's room, surveyors observed trash and debris on the floor, including straw wrappers, a napkin, and food crumbs scattered around the room. R14 stated housekeeping did not sweep and mop her room daily, that the floor was often covered with crumbs and trash, and that trash cans were not emptied until they overflowed. In R6 and R13's room, surveyors observed multiple trash items on the floor, including a wound dressing dated 04/26/2026 behind the trash can, debris along the wall and baseboard, contaminated gloves under the bed, multiple pairs of gloves on the bedside table, and used tissues and debris on the floor. R6 stated her room had not been cleaned over the weekend and that nursing staff threw discarded gloves on the floor and sometimes left extra supplies in her room, making it cluttered and untidy. In R26's room, the bed was visible from the hallway, the bed was unmade, and the linens were visibly soiled with stains on the top sheet, fitted sheet, and pillowcase. Crumbs were observed across the fitted and draw sheets, along with what appeared to be fecal smearing on the draw sheet, and used tissues were present in the bed. SRNA1 stated she had gotten R26 dressed and out of bed and had not yet cleaned the room, and that she tried to make the bed and straighten up the room after getting residents up for the day. In R93's room, the privacy curtain was pushed back near the head of the bed, a portion of the curtain was lying on the floor, multiple hooks were missing, and trash including used mouth swabs was observed on the bedside table and floor. Family and staff interviews stated resident rooms were not always kept tidy, especially during call-ins or on weekends, and that housekeeping staffing was reduced on weekends compared with weekdays.
Failure to Provide Written Transfer and Bed Hold Notices
Penalty
Summary
The facility failed to send written notice of transfer to the resident’s representative, including the reason for the transfer, the effective date of the transfer, the duration of the bed hold, and the facility’s bed hold policy, for 2 of 3 residents reviewed for Admission, Transfer, and Discharge. The deficiency involved two residents who were transferred to local emergency departments by EMS after acute events, and the record review showed no transfer notice or bed hold documentation in either resident’s medical record. One resident was admitted with diagnoses including Parkinson’s disease with dyskinesia, repeated falls, and cognitive communication deficit, and had a BIMS score of 11 out of 15, indicating moderate cognitive impairment. That resident was transferred to the ED after radiology reports showed a fractured femur. The resident’s family member stated she was not informed of the transfer/discharge paperwork or the facility’s bed hold policy and did not receive written transfer or bed hold information in person or by mail after the hospitalization. The second resident was admitted with diagnoses including Alzheimer’s disease, dementia, and anxiety, and had a BIMS score of 3 out of 15, indicating severe cognitive impairment. That resident was transferred to a local ED by EMS for evaluation after a fall. The record contained no transfer information or copy of transfer notice/bed hold documentation, and the resident’s family member could not be reached for interview. Facility staff stated a transfer form was provided to EMS, but they could not confirm that written notification was mailed to the resident’s representative or identify where such documentation was maintained.
Failure to Keep Urinary Catheter Drainage Bag Covered
Penalty
Summary
The facility failed to promote and maintain resident dignity for one sampled resident with an indwelling urinary catheter. R93 was admitted on 04/23/2026 with diagnoses including unspecified protein-calorie malnutrition, benign prostatic hyperplasia, and aphasia following cerebral infarction. The resident’s MDS showed a BIMS score of 12 out of 15, indicating moderate cognitive impairment, and confirmed the presence of an indwelling urinary catheter. The care plan, dated 04/25/2026, included a focus for the urinary catheter, but there were no interventions related to the resident’s refusal of a dignity bag cover. Observations on 04/27/2026, 04/28/2026, and 04/29/2026 showed the urinary catheter drainage bag was not placed inside the dignity cover and remained visible from the hallway or outside the resident’s room. On one observation, the bag was attached to the bed frame while the dignity cover hung beside it; on another, the bag was secured to the bed without a cover in place. During an attempted interview, R93 was unable to answer questions due to aphasia and communication difficulty, so surveyors could not determine whether the resident refused the cover or how the resident felt about the bag being visible. Staff interviews indicated that dignity covers were expected to be used to protect privacy and dignity, and the Medical Director, DON, and Administrator all stated that urinary catheter drainage bags should remain covered.
Failure to Follow Hand Hygiene and EBP PPE Requirements
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases. The deficiency involved one sampled resident, R93, who was admitted on 04/23/2026 with diagnoses including unspecified protein-calorie malnutrition, benign prostatic hyperplasia, and aphasia following cerebral infarction. R93’s admission MDS showed a BIMS score of 12 out of 15, indicating moderate cognitive impairment, and the resident had an indwelling urinary catheter and a G-tube. The resident’s orders showed enhanced barrier precautions were in place related to a wound, G-tube, and urinary catheter. On 04/27/2026 at 9:16 AM, LPN3 exited R93’s room wearing gloves after providing care and did not remove the gloves or perform hand hygiene. She touched the top of the medication cart with the contaminated gloves, used the same gloves to remove a plastic cup from the stack of cups, and then returned to the resident’s room without removing the gloves or cleaning her hands. During interview, LPN3 stated she did not remove her gloves because they were not dirty. She did not answer when asked whether she had provided care to R93 before exiting the room. On 04/28/2026 at 8:10 AM, UM1 performed oral care for R93 and then handled the resident’s G-tube while leaning against the bed. The G-tube cap was open, and an enteral syringe containing a pink colored liquid was on the overbed table. UM1 did not wear the required gown while providing this high-contact direct care for a resident on EBP. During interview, UM1 stated she was only holding the G-tube and did not believe a gown was necessary because she was not providing high-contact care. The IP, DON, Medical Director, and Administrator all stated staff were expected to follow the facility’s infection control and EBP policies, including hand hygiene and use of gowns and gloves for G-tube care and other high-contact direct care.
Failure to Maintain Sanitary Food Preparation and Service Conditions
Penalty
Summary
Surveyors observed multiple failures in food preparation and service practices that did not meet professional standards for sanitation and safety. During kitchen tours and meal service observations, dome lids for resident plates were found stacked while still wet, with visible condensation and beads of water inside. Staff interviews confirmed that dome lids were sometimes dried with a towel or only briefly air-dried before being put away, contrary to the facility's written procedure requiring full air-drying to prevent contamination. During meal service, the Food and Beverage Director (FBD) was seen taking food temperatures by inserting a thermometer through plastic wrap covering the food, which is not consistent with USDA guidelines for accurate temperature measurement. Additionally, a significant discrepancy was noted when the puree chicken's temperature was first recorded as 168°F, but upon rechecking, it was only 119°F, prompting the FBD to request reheating. This indicates that food was placed on the tray line for service without confirming it had reached a safe internal temperature. Staff were also observed changing gloves and performing different tasks without proper hand hygiene, such as not washing hands after removing gloves and before resuming food handling. Interviews with staff and the FBD acknowledged the importance of hand washing and glove use to control bacteria, but also revealed that these practices were not consistently followed, especially when staff felt rushed. The DON and Administrator both stated expectations for safe food handling, accurate temperature checks, and proper hand hygiene, but these standards were not met during the survey period.
Failure to Post Enhanced Barrier Precautions Signage for Residents with Active Orders
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically regarding the implementation of Enhanced Barrier Precautions (EBP) for five residents who had active orders for EBP due to wounds or indwelling medical devices. Observations conducted over several days revealed that none of these residents had EBP signage posted outside their rooms, as required to inform staff and visitors of the necessary infection control measures when entering or exiting the rooms. The absence of appropriate signage was noted despite the presence of active EBP orders in the residents' clinical records. The facility's policies on infection prevention and control, as well as EBP, were reviewed. The policy on transmission-based precautions did not describe EBP, and the EBP policy, while outlining the use of gowns and gloves during high-contact care activities, did not ensure that signage was consistently posted. Interviews with staff, including CNAs, the Staff Development Coordinator, the Infection Preventionist Nurse, and the Director of Nursing, confirmed that staff relied on signage to determine the required personal protective equipment (PPE) and that the lack of signage could result in staff and visitors not following proper precautions. Staff also indicated that the residents' precaution status was not always available in other documentation, such as the Kardex, making signage the primary method of communication. Further, the MDS Nurse, who often entered the EBP orders, stated she did not place signage and was unsure of the required timing for signage placement. The Infection Preventionist Nurse and Director of Nursing both stated their expectation that signage should be posted immediately after an order was received, but this was not consistently done. The Administrator also confirmed that signage should be posted as soon as possible after an order is received and that the nurse receiving the order is responsible for ensuring this occurs. The lack of EBP signage for residents with active orders constituted a failure to maintain a safe and sanitary environment and to prevent the transmission of communicable diseases and infections.
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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 | 0.8 mi | ★★★★★ | 0 | 0 |
| Homestead Post Acute | 0.9 mi | ★★★★★ | 0 | 0 |
| Cardinal Hill Skilled Rehabilitation Unit | 1.1 mi | ★★★★★ | 0 | 0 |
| Cambridge Nursing & Rehabilitation Center | 1.6 mi | ★★★★★ | 6 | 0 |
| Mayfair Manor | 3.2 mi | ★★★★★ | 7 | 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 August 2026) and official state health department websites.