Below 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 Lexington Premier Nursing & Rehab during CMS and state inspections, most recent first.
Surveyors found stained, dirty, and unraveling carpets in several facility areas, with no documented cleaning procedures provided. Staff interviews confirmed the importance of cleanliness for infection prevention and resident comfort, while the CEO cited incomplete carpet replacement due to financial issues.
A resident council meeting was held in a dining area that staff walked through to access the kitchen, and residents reported repeated disruptions from employees entering, exiting, and speaking loudly during the meeting. Residents stated the meetings were held there every month without privacy, while the Activities Director said the facility had ongoing difficulty finding a private space and the DON and CEO were unaware the meeting was being disrupted.
Food Served at Unappetizing Temperatures: Breakfast trays on the South 200 Unit were delivered over a 20-minute period, and when the DM checked temperatures at point of service, sausage and cheesy eggs were below palatable temperatures while oatmeal was acceptable. The facility’s policy called for hot foods on room trays to be at least 120 degrees F for palatability, and residents reported breakfast was sometimes cold when delivered to rooms.
The facility failed to document COVID-19 vaccine screening, education, offering, and current vaccination status for 5 sampled staff members, including an RN, an LPN, and 3 SRNAs. Record review showed missing evidence of vaccine offers and education on benefits, risks, and side effects, and two SRNAs stated they were never educated or asked about their vaccination status. Leadership also stated the facility did not have a COVID-19 immunization policy and did not maintain declination or vaccination documentation.
Nursing staff did not follow professional standards for medication administration when a nurse prepared medications for a resident and handed them to an LPN, who then administered them without having prepared them personally. Staff interviews confirmed this was not acceptable practice, and facility policy required LPNs to administer only medications they had prepared themselves.
Call Light Left Out of Resident’s Reach: A resident with COPD, respiratory failure, and intact cognition was observed lying in bed with the call light on the floor and out of reach. Facility policy and multiple staff interviews stated call lights were to remain within residents’ reach at all times so they could contact staff when assistance was needed.
Failure to Provide Written Transfer/Discharge and Bed Hold Notices: The facility did not document that it gave written notice to residents and/or their representatives explaining the reason for hospital transfer/discharge or the bed hold policy, including reserve bed payment, and did not send copies to the ombudsman for 3 sampled residents. The affected residents had diagnoses including Parkinson’s disease, COPD, CHF, respiratory failure, dementia, and stroke-related deficits, and were sent to the hospital for issues such as abdominal pain, altered mental status, decreased urine output, and possible stroke. Staff described phone calls and packet information, but proof of the required written notices was not provided.
Failure to Care Plan Chronic Pain: A resident with severe dementia and chronic pain had scheduled narcotics and PRN pain meds ordered, but the CCP did not include pain management goals or interventions. Surveyors observed the resident crying, moaning, grimacing, and showing other non-verbal signs of discomfort while lying in bed. Staff repositioned the resident and gave PRN pain medication after the issue was brought to their attention, and the DON stated the resident should have had a pain care plan based on assessment.
Expired medications and supplies were found in a rehab medication room and treatment cart, including wound dressings, lubricating jelly, and Santyl ointment. An opened insulin vial had no opened date, and an opened inhaler had an opened date and discard timeframe noted. The facility’s medication policy lacked storage details, while staff job descriptions and interviews showed expectations for proper labeling, disposal, and storage of medications.
An LPN failed to use the required PPE and hand hygiene while performing fingersticks for residents under EBP, and he carried and briefly disinfected a contaminated glucometer without following the wipe’s dwell time or proper storage practices. Staff also entered a resident’s contact precaution room without the required gown and gloves, and some staff were unaware of the reason for the isolation precautions despite posted CDC signage and facility policies requiring hand hygiene, PPE use, and proper disinfection of shared equipment.
Failure to Maintain Clean and Homelike Environment Due to Stained and Unraveled Carpets
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, comfortable, and homelike environment for residents, as evidenced by stained and unraveled carpet in multiple areas. On several occasions, the carpet in the front lobby, North Hall, and South Hall was found to be visibly dirty, stained, and unraveling. When the State Survey Agency requested an environmental policy, only blank cleaning logs were provided, indicating a lack of documented cleaning procedures. Interviews with staff, including an RN, ADON, and Administrative Assistant, confirmed the importance of maintaining clean carpets for infection prevention and to ensure a positive impression for residents and visitors. The CEO acknowledged that only part of the carpet replacement project had been completed due to financial constraints and was unaware of standard infection control practices. The observations and staff interviews collectively demonstrate the facility's failure to provide a clean and homelike environment as required.
Resident Council Meeting Held in Non-Private Dining Area
Penalty
Summary
The facility failed to provide residents and the resident/family group with a private space for the monthly Resident Council meeting. On 08/05/2025, the Resident Council meeting was observed taking place in the dining room, which was a non-private area used by staff to pass through for access to the kitchen. Employees entered and exited the area during the meeting, and residents stated that staff walking through the room disrupted the meeting with noise and interruptions. Resident interviews during the meeting confirmed that the dining hall was used every month and that staff routinely walked through the space or entered and sat in the meeting without resident approval. One resident stated staff had another door they could use to access the kitchen without interfering with the meeting. The Activities Director stated the facility had ongoing difficulty finding a private space due to limited space, and the DON stated she was unaware the meetings were being disrupted and believed signs were posted. The CEO stated he was unaware residents were requesting a private space, but acknowledged that if they were, the facility should provide one.
Food Served at Unappetizing Temperatures
Penalty
Summary
Food and drink were not provided at palatable, attractive, and safe temperatures during breakfast service on the South 200 Unit. Observation of the breakfast test tray showed hot foods were at unappetizing temperatures at the point of service. The facility’s policy for In-Room Dining stated hot foods served on room trays were preferred to be at 120 degrees Fahrenheit or greater to promote palatability, and the facility’s Food Temperature Chart showed cooked cereal, eggs, and sausage were all hot when first measured on the tray line and remained hot at the conclusion of the tray line. During breakfast delivery, a trolley of 20 trays and a smaller cart with six trays arrived on the unit, and trays were delivered to residents over a 20-minute period. When the Dietary Manager took temperatures at 8:15 AM, the sausage patty measured 77 degrees F, cheesy eggs measured 104 degrees F, and oatmeal measured 144 degrees F. The surveyor tasted the food and found the sausage was not warm enough to be palatable, the cheesy eggs would have tasted better if warmer, and the oatmeal was palatable. Residents in the Resident Council stated food was sometimes cold when delivered to rooms, with breakfast cited as cold more often than other meals. The Dietary Manager stated his expectation was that temperatures be no less than 105 degrees F at point of service, and the DON stated her expectation was that food be at the correct temperature when residents received it.
Missing COVID-19 Vaccine Education and Documentation for Staff
Penalty
Summary
The facility failed to maintain documentation of screening, education, offering, and current COVID-19 vaccination status for 5 of 5 sampled staff members: RN 2, LPN 2, SRNA 10, SRNA 11, and SRNA 12. Review of the CMS QSO-21-19-NH memo showed that LTC facilities must offer staff COVID-19 vaccination when vaccine supplies are available and must screen staff before offering vaccination for prior immunization, medical precautions, and contraindications. Review of the facility’s Infection Control policy showed the facility would plan control activities and manage potential outbreaks of disease, but the facility did not provide a COVID-19 Immunization Policy. Record review showed RN 2’s file had no documented evidence that the vaccine was offered and no documentation of education on the benefits, risks, and potential side effects. LPN 2’s file had no documentation of vaccine education. SRNA 10, SRNA 11, and SRNA 12 also had no documented evidence of education regarding the benefits, risks, and potential side effects of the COVID-19 vaccine. SRNA 10 and SRNA 11 stated during interview that they had not been educated about or asked regarding their COVID-19 vaccination status, had not signed any related forms, and were not required to present a vaccination card or sign documentation. The HRD, IP, DON, and AA stated the facility did not provide in-house COVID-19 vaccinations, did not have a COVID-19 Immunization Policy, and did not maintain documentation supporting staff education, declination forms, or employee vaccination status.
Failure to Ensure Proper Medication Administration by Nursing Staff
Penalty
Summary
Nursing staff failed to follow professional standards of medication administration for one resident. Observation revealed that the North Unit Nurse Manager prepared a cup of 14 medications for a resident and then handed the cup to an LPN, who subsequently administered the medications to the resident. The LPN had been away from the medication preparation area during the process, retrieving a nutrition supplement, and did not personally prepare the medications. The facility's policy and LPN job description indicated that LPNs are expected to administer only medications they have personally prepared and not to leave medications at the bedside without an order. Multiple staff interviews confirmed that it was not acceptable practice to prepare medications and have another nurse administer them, citing safety concerns and lack of knowledge about the contents of the medication cup. The DON and interim Administrator both stated their expectation that staff should prepare and administer medications individually, and not hand off medications to another staff member for administration. The facility's policy did not provide specific guidelines for situations where more than one nurse is involved in medication administration for a single resident.
Call Light Left Out of Resident’s Reach
Penalty
Summary
The facility failed to ensure a resident had reasonable accommodation of needs and access to services when the resident's call light was found on the floor and out of reach during observation. The resident, admitted with diagnoses including acute and chronic respiratory failure with hypoxia, COPD, and age-related cognitive decline, had a quarterly MDS showing a BIMS score of 14 out of 15, indicating the resident was cognitively intact. Facility policies reviewed stated that staff were to ensure call lights were within reach during interactions and that residents had access to communication and services inside and outside the facility. During observation, the resident was lying in bed in the room while the call light was located on the floor on the right side of the bed and could not be reached. Multiple staff members interviewed stated call lights were expected to be kept within residents' reach at all times and not placed on the floor, and that residents depended on them to contact staff when assistance was needed. The RN, ADON, unit manager, and DON all stated it was their expectation that call lights remain accessible so residents could reach staff when needed.
Failure to Provide Written Transfer/Discharge and Bed Hold Notices
Penalty
Summary
The facility failed to provide documentation that it notified residents and/or their representatives in writing of the reason for transfer or discharge to the hospital or of the facility’s bed hold policy, including reserve bed payment. The facility also failed to notify or send a copy of the notice to the ombudsman for 3 of 4 sampled residents: R9, R37, and R54. The facility’s policy titled, Transfer and Discharge from the Facility, dated 01/2024, stated residents and representatives would receive timely notification and written information about the transfer, including appeal rights, and that copies of discharge notices would be forwarded to the Office of the State Long-Term Care Ombudsman and required state agencies. R9 was admitted with diagnoses including Parkinson’s disease, COPD, and CHF, and had a BIMS score of 11/15, indicating moderate cognitive impairment. A progress note dated 07/31/2025 documented that R9 was sent to an outside hospital for evaluation after complaints of abdominal pain. R54 was admitted with diagnoses including acute and chronic respiratory failure with hypoxia, COPD, and age-related cognitive decline, and had a BIMS score of 14/15, indicating cognitive intactness. A progress note dated 05/17/2025 documented that R54 was sent to the hospital due to altered mental status and decreased urine output. R37 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, dementia, and pneumonia, and had a BIMS score of 8/15, indicating moderate cognitive impairment. Progress notes documented that R37 was sent out by emergency services for a possible stroke on 05/06/2025 and later sent to the hospital on 05/17/2025 due to altered mental status and decreased urine output. During interviews, staff stated transfer/discharge information and bed hold information were provided through forms, telephone calls, or admission packets, but the surveyor requested proof that written notification was sent to the resident, representative, and ombudsman, and that information was not received.
Failure to Care Plan Chronic Pain
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with chronic pain, including measurable objectives and timeframes to meet the resident’s medical, nursing, and psychosocial needs. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbance, COPD, and dysphagia following cerebral infarction, and was not assessed with BIMS because of severe memory and communication impairment. The facility’s policy required a comprehensive care plan based on the resident’s assessment, but the resident’s comprehensive care plan, revised 06/24/2025, did not include pain management goals or interventions despite the resident’s documented chronic pain. The resident’s pain evaluation documented non-verbal expression of pain, including moaning, grimacing, and increased pain with movement during care and dressing changes. The evaluation also noted that pain medications effectively relieved discomfort and identified the current regimen as narcotics. Physician orders included instructions to observe for signs or complaints of pain, address all pain with appropriate interventions, report uncontrolled pain each shift, and administer oxycodone 10 mg four times daily for pain, along with scheduled and PRN acetaminophen. The MAR showed the resident received scheduled oxycodone and tramadol as ordered. On observation, the resident was lying in bed and displayed clear non-verbal signs of discomfort, including intermittent crying, moaning, grimacing, a furrowed brow, bracing with her arms, and frequent repositioning. She was unable to participate in an interview or express her needs. Staff repositioned her and administered PRN pain medication after the surveyor requested the unit manager check on her. During interviews, staff stated the resident was non-verbal, could respond by nodding, and had pain medications administered as ordered. The DON stated the resident should have had a pain care plan based on assessment, with specific goals and interventions, and that staff should respond promptly to non-verbal cues and assess for non-pharmacological interventions.
Expired and Improperly Labeled Medications Found in Medication Rooms and Carts
Penalty
Summary
The facility failed to correctly label opened medications and dispose of expired medications and supplies in 1 of 3 medication rooms and 3 of 8 medication and treatment carts. During observation of the Rehab Unit Medication Room, expired items were found available for resident use, including a Biopatch wound dressing expired 3/31/2024, 31 lubricating jelly packets expired 10/28/2023, one box of Surgilube lubricant expired June 2023, and nine DermaFoam dressings expired 02/20/2024. Observation of the Rehab Treatment Cart also revealed expired items available for use, including R88’s Santyl ointment expired 05/2025, a Hydrocellular Foam Dressing expired 06/2020, and a nonbordered Mepilex dressing expired 04/01/2023. Additional observations showed medication storage issues on other carts. The North Unit Medication Cart 3 contained an opened vial of Admelog insulin with no opened date on the box or vial. The South Unit Medication Cart 3 contained an opened Ellipta inhaler with an opened date of 03/17/2025 and a discard-after-six-weeks notation. The facility’s Medication Administration policy did not include medication storage details, although LPN and RN job descriptions included duties related to disposing of drugs appropriately, checking in medications, restocking carts, and maintaining proper storage. Staff interviews confirmed that expired items should not be used because they may not be safe or effective, and the DON stated nursing staff were expected to ensure proper labeling and return or discard medications as appropriate.
Infection Control Failures With PPE Use and Equipment Disinfection
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 3 sampled residents, including a resident under enhanced-barrier precautions (EBP), a resident under contact precautions for colonization with carbapenem-resistant acinetobacter baumannii, and a resident with diabetes and other diagnoses. The report identified failures related to hand hygiene, use of personal protective equipment (PPE), and cleaning and disinfection of shared equipment. The facility policies and CDC guidance reviewed by surveyors required hand hygiene, gown and glove use for EBP and contact precautions, and proper cleaning and disinfection of reusable resident-care equipment. An LPN performed a blood sugar fingerstick for one resident and then went to perform a fingerstick on another resident without donning the appropriate PPE for the resident under EBP and without performing hand hygiene before entering the room. The LPN then carried a contaminated glucometer from one room to another, placed it on the medication cart without a barrier cloth, and disinfected it for only 15 seconds before returning it to storage. During interview, the LPN stated glucometers should be cleaned after each use and acknowledged he should have performed hand hygiene and worn the appropriate PPE, but he was unable to explain dwell time or the required dwell time for the wipes used. For the resident under contact precautions, staff interviews and observations showed that staff were unaware of the reason for the transmission-based precautions and entered the room without first putting on the required PPE. A SRNA stated she did not know the source of the resident’s infection and had not received that information in report. A housekeeping employee also entered the room without gloves or a gown and stated she had not been trained to don PPE for that resident and did not know anything about the precautions. Additional staff interviews reflected that some staff understood the signage and PPE requirements, while others were uncertain about the resident’s isolation status and the reason for the precautions.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| The Willows At Hamburg | 1.5 mi | ★★★★★ | 0 | 0 |
| Bluegrass Care & Rehabilitation Center | 2.7 mi | ★★★★★ | 0 | 0 |
| Mayfair Manor | 3.3 mi | ★★★★★ | 7 | 0 |
| Hartland Park Health & Rehabilitation | 3.6 mi | ★★★★★ | 4 | 0 |
| Sayre Christian Village Nursing Home | 4.4 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.