Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 House during CMS and state inspections, most recent first.
A resident’s family voiced concerns that staff were “mean and rude,” and an LPN documented the complaint in the EHR and said she notified the DON. However, no grievance was opened in the facility’s log or computer system, and the Admin and DON both confirmed that the complaint had not been formally documented or investigated.
Surveyors found that staff failed to keep call lights within reach for three dependent residents with conditions such as hemiplegia, muscle weakness, gait abnormalities, and a history of falls. In each case, the call light was observed hanging off the side of the bed or lying on the floor, and the resident reported being unable to locate it. CNAs and an LPN acknowledged that call lights were supposed to be on the bed and within residents’ reach at all times, consistent with facility policy, but this was not done for these residents.
A resident with severe cognitive impairment, hemiplegia, and a left AKA reported right lower extremity pain, and imaging confirmed traumatic fractures of the tibia and fibula. The facility classified this as an injury of unknown origin but did not complete a thorough investigation as required by policy: a CNA who had provided care in the 48 hours before the injury was not interviewed or asked for a statement, and the administrator, despite having access to 72 hours of video surveillance, reviewed only the most recent 24 hours prior to discovery of the injury.
A CNA instructed a resident with moderate cognitive impairment and multiple health conditions not to use the call light because she was busy, an action confirmed by both the CNA and the DON as inappropriate and disrespectful. The resident reported this was not the first occurrence, and facility policy requires staff to treat all residents with dignity and respect.
Staff were observed preparing pureed foods without measuring portions or following prescribed recipes, instead relying on visual estimation. The dietary aide and manager both confirmed that recipes were not followed, and the dietician noted this could result in inaccurate nutritional content for residents on pureed diets. This practice had the potential to affect multiple residents receiving pureed diets.
The facility did not maintain a clean and sanitary kitchen, with unlabeled open food items, staff not wearing required hair and beard restraints, unsanitary air conditioner vents, and improper dish sanitization practices. Logs for dishwasher temperatures were also incomplete, and these failures had the potential to affect all residents receiving meals.
A resident with severe cognitive impairment and total care needs was repeatedly observed in bed with the call light on the floor and out of reach, despite facility policy and the care plan requiring it to be accessible. Staff confirmed the call light was not within reach as required.
Two residents were not given the required SNF ABN (CMS-10055) before their Medicare Part A services were discontinued, even though benefit days remained. In both cases, the Accounts Manager stated she was unaware of the need to provide this notice prior to ending skilled services, and both residents continued to reside in the facility after skilled services ended.
Two residents were affected by the facility's failure to follow and develop person-centered care plans. One resident, with moderate cognitive impairment and multiple chronic conditions, was found keeping cigarettes and a lighter in her wheelchair pouch despite a care plan and policy requiring these items to be stored at the nurses' station. Another resident with severe cognitive impairment and a history of eating non-food items was not timely care planned for this behavior, even after multiple incidents of chewing or ingesting non-food items were documented. Staff confirmed these lapses during interviews and record reviews.
The facility did not ensure physician-ordered wound care was provided and documented for three residents with complex medical needs, including pressure ulcers, diabetic ulcers, and skin tears. Wound care was missed or undocumented on multiple occasions, and staff confirmed that treatments were not completed as required.
The facility did not ensure accurate documentation and proper witnessing procedures for controlled medication administration and wasting. An LPN failed to document the administration of a narcotic tablet at the time of administration for a resident, and in a separate case, two narcotic tablets wasted by a nurse lacked the required witness signature. Facility leadership confirmed that staff were aware of these documentation and witnessing requirements.
A resident with multiple medical conditions, including Alzheimer's and a history of UTIs, was observed on several occasions without a water pitcher or fluids at the bedside, despite facility policy and care plan requirements for regular fluid provision. Staff confirmed the resident had no fluid restrictions and should have had fluids available, but documentation showed inconsistent fluid offers.
A resident with a history of UTIs did not receive timely and appropriate treatment due to a breakdown in the facility's process for handling lab results. Despite a culture and sensitivity test indicating resistance to the initially prescribed antibiotic, the resident continued to receive inappropriate treatment until much later, when the correct antibiotic was finally administered.
Failure to Document and Investigate a Resident Grievance
Penalty
Summary
The facility failed to ensure that grievances and complaints were documented and investigated for 1 of 37 sampled residents, Resident #9. The facility’s grievance policy stated that when a complaint or grievance is voiced, a grievance/complaint form would be completed by the Administrator or Department Head with follow-up as appropriate. Review of the resident’s record showed an admission date of 02/12/2026 and diagnoses including encounter for surgical aftercare following surgery on the nervous system, type 2 diabetes mellitus with diabetic polyneuropathy, syncope and collapse, and generalized muscle weakness. An EHR nursing note written by an LPN on 04/06/2026 at 2:20 p.m. documented that the resident’s family told the nurse the resident did not want to be there because staff was “mean and rude to her,” and the note included additional concerns voiced by the resident or family member. Review of the 2026 grievance/complaint log did not show a grievance for this concern. The LPN stated she notified the DON about the grievance/complaint as relayed by the family, while the Admin stated only the Administrator or Department Head could open a grievance in the computer system and said she was unaware of the family’s concerns. The DON stated that a grievance/complaint had not been opened regarding the concern voiced by the family on behalf of the resident.
Failure to Keep Call Lights Within Reach of Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring that call lights were accessible to multiple residents, contrary to the facility’s own call light policy requiring staff to place the call light within the resident’s reach before leaving the room. For Resident #2, who had hemiplegia, generalized muscle weakness, repeated falls, and was dependent for toileting, hygiene, bathing, dressing, rolling, and transfers, surveyors observed the call light hanging off the left side of the bed, dangling below the bottom of the mattress. Resident #2 stated she was unable to locate the call light. When accompanied by S4LPN, it was confirmed that the call light was not within reach but should have been accessible to the resident at all times. For Resident #3, who had hemiplegia, paroxysmal atrial fibrillation, muscle weakness, syncope and collapse, a history of falling, and severely impaired cognition with a BIMS score of 3, surveyors observed the call light hanging off the left side of the bed near the floor. Resident #3 reported being unable to locate the call light, and S11CNA confirmed that the call light was not within reach and should have been. For Resident R4, who had abnormalities of gait and mobility, generalized muscle weakness, age-related physical debility, and repeated falls, surveyors observed the resident lying in bed with the call light on the floor to the left of the bed. S6CNA confirmed that this call light also was not within reach but should have been. Additional interviews with S10LPN and S3QI confirmed that facility practice and expectations were for call lights to be on the bed, within reach of residents, and in their hand when possible, reinforcing that the observed situations represented failures to follow established procedures.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident. The resident had diagnoses including hemiplegia, hemiparesis, dementia, and a left above-knee amputation, and was dependent for hygiene, bathing, dressing, and position changes. A Significant Change MDS showed a BIMS score of 3, indicating severely impaired cognition. On a specified date, the resident complained of pain to the right lower extremity, and x‑rays of the right knee, tibia, and fibula demonstrated traumatic fractures of the proximal tibial and fibular diaphyses and tibial shaft. The facility completed a Critical Incident Report and substantiated an injury of unknown origin based on its policy criteria that the source of the injury was not observed, could not be explained by the resident, and was suspicious due to the extent and location of the injury. Despite policy requirements that the administrator thoroughly investigate all alleged violations and injuries of unknown origin, the investigation was incomplete. Nursing staff who rendered care during the 48 hours prior to discovery of the injury were to provide statements, but a CNA who provided care to the resident from 3:00 p.m. to 11:00 p.m. on the two days before the injury was identified was not interviewed or asked for a statement, even though she confirmed she had provided care during that period. Additionally, the administrator had access to 72 hours of facility video surveillance footage prior to discovery of the injury but reviewed only the previous 24 hours and acknowledged not reviewing the full 72-hour period prior to the injury, despite stating she should have done so.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
Facility staff failed to treat a resident with respect and dignity, as required by facility policy and federal regulations. During an observation, a CNA told a resident not to use the call light anymore because she was busy. The CNA later confirmed to the surveyor that she made this statement and acknowledged it was rude. The resident, who has moderate cognitive impairment and multiple medical conditions including congestive heart failure, diabetes, and dementia, reported that this was not the first time the CNA had told her not to use the call light. At the time of the incident, the resident was observed sitting in her wheelchair with her head down and expressed that she did not want to be told not to use her call light. The Director of Nursing confirmed that it was not the expectation for any staff member to instruct a resident not to use the call light, regardless of how busy they were. The facility's policy on dignity and respect requires staff to display respect when speaking with and caring for residents, and to promote the rights of residents to a dignified existence and self-determination. The actions of the CNA were inconsistent with these requirements and resulted in a failure to ensure the resident was treated with respect and dignity.
Failure to Follow Pureed Diet Recipes During Meal Preparation
Penalty
Summary
The facility failed to ensure that recipes for pureed diets were followed during meal preparation, as observed during a lunch service. A dietary aide was seen preparing pureed foods without measuring portions or adhering to the prescribed recipes, instead relying on visual estimation based on the pan size. The dietary aide confirmed that recipes and measurements were not used when preparing pureed foods. The dietary manager also confirmed that the aide did not follow the required recipes and acknowledged this was not the first occurrence, referencing prior disciplinary action. Additionally, the facility dietician confirmed that failure to follow pureed recipes could result in inaccurate nutritional content for residents receiving pureed diets. This practice had the potential to affect twelve residents who were on pureed diets.
Failure to Maintain Sanitary Kitchen and Adhere to Food Safety Standards
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment and did not adhere to professional standards for food storage, preparation, and service. Observations revealed that food items in the pantry, such as an open bag of penne pasta, were not labeled with an open date as required. Staff were observed not wearing appropriate hair restraints, including beard restraints, while preparing food, and it was confirmed that beard restraints were unavailable at the time. Additionally, the kitchen's air conditioner vents were found to be unsanitary, covered in a black substance, and there was uncertainty regarding the last time they had been cleaned. Further deficiencies were identified in the dish sanitization process. A dietary aide was observed failing to properly sanitize dishes using the 3-compartment sink, with the sanitization strip being non-reactive on two attempts and the sanitization hose placed in the wrong compartment. The chemical sanitizer was not mixed to the proper concentration, and there was no evidence that water temperature or sanitizer levels were checked or recorded as required. Review of dishwasher temperature logs also revealed missing entries for multiple dates. These failures had the potential to affect all 115 residents who received meals from the kitchen.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical diagnoses, including Alzheimer's, dementia, and limited mobility, was not provided reasonable accommodation for their needs. The facility's policy and the resident's care plan both required that the call light be placed within the resident's reach to allow communication with staff. However, during multiple observations over two days, the call light was found on the floor next to the resident's bed, out of the resident's reach, while the resident was lying in bed and unable to access it. The resident was non-interviewable and required total care and extensive assistance for bed mobility. Staff confirmed during the survey that the call light was not accessible and acknowledged that it should have been within reach, as per facility policy and the resident's care plan. The repeated failure to ensure the call light was accessible constituted a lack of reasonable accommodation for the resident's needs and preferences.
Failure to Provide Required SNF ABN Prior to Discontinuation of Medicare Services
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN, Form CMS-10055) to residents or their responsible parties prior to discontinuing Medicare Part A services, as observed in the cases of two residents. One resident was discharged from Physical and Occupational Therapy due to non-compliance or refusal to participate, despite having Medicare benefit days remaining. The Accounts Manager confirmed that the SNF ABN was not provided because she was unaware of the form or the requirement to send it before discontinuing skilled services. Similarly, another resident was discharged from Medicare Part A services when benefit days were still available, due to cognitive inability to participate in therapy. The Accounts Manager again confirmed that the SNF ABN was not sent to the resident or their responsible party, citing lack of awareness of the form and its required use prior to discharge from skilled services. Both residents remained in the facility after skilled services were discontinued.
Failure to Implement and Develop Person-Centered Care Plans for Smoking Safety and Pica Behaviors
Penalty
Summary
The facility failed to develop and implement person-centered care plans for two residents, resulting in deficiencies related to smoking safety and management of pica behaviors. For one resident with chronic respiratory failure, COPD, diabetes, and moderate cognitive impairment, the care plan specified that cigarettes and lighters should be kept at the nurses' station and only provided upon request in designated smoking areas. However, observations and interviews revealed that the resident regularly kept a pack of cigarettes and a lighter in her wheelchair pouch, contrary to the care plan and facility policy. Staff confirmed that smoking supplies were not being stored as required. Another resident with severe cognitive impairment, dementia, and a history of eating non-food items was not timely care planned for this behavior. Progress notes documented multiple incidents where the resident chewed or ingested non-food items such as straws, plastics, paper, and cloth. During an observation, the resident was found chewing on string-like material and holding a bib with holes, with staff needing to remove pieces of cloth and food from her mouth. Despite these documented behaviors, the care plan did not initially address the risk of eating non-food items, and staff confirmed the absence of a relevant care plan focus during the review period. These deficiencies were identified through record review, staff and resident interviews, and direct observation, demonstrating a lack of adherence to established care plans and failure to timely address known behavioral risks for the affected residents.
Failure to Provide Wound Care as Ordered for Multiple Residents
Penalty
Summary
The facility failed to provide care and services that met professional standards of quality by not ensuring that physician's orders for wound care were implemented as prescribed for three residents. For one resident with chronic respiratory failure, dysphagia, cognitive deficits, and a Stage 3 sacral pressure ulcer, wound care orders were not followed as documented in the Treatment Administration Record (TAR). The wound care was missed on multiple days in April and May, with the Director of Nursing (DON) confirming that documentation was lacking and care was not completed as ordered. Another resident with diabetes, a recent amputation, peripheral vascular disease, and a diabetic foot ulcer also did not receive wound care as ordered. The electronic TAR (eTAR) showed that wound care for the diabetic ulcer and for moisture-associated skin damage (MASD) to the buttocks was not completed on several days in April and May. The DON acknowledged that wound care was not documented or completed as required by the physician's orders. A third resident with chronic respiratory failure, COPD, Parkinson's disease, and dementia had a skin tear to the right eyebrow. The care plan required daily wound care, but there was no evidence of an order to complete this care in the eTAR, and observations revealed the dressing was undated and the wound had dried blood. An LPN confirmed that the treatment should have been performed daily and the dressing should have been dated, but this was not done.
Failure to Accurately Document and Witness Controlled Medication Administration and Wasting
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administration of medications for its residents. Specifically, during a controlled medication reconciliation, it was found that a nurse administered a Clonazepam tablet to a resident but did not document the administration in the clinical record at the time it occurred. The nurse confirmed the omission, and facility leadership acknowledged that all floor nurses were aware of the requirement to document narcotic administration promptly in the clinical record. Additionally, the facility did not follow proper procedures for wasting or destroying narcotic medications. In one instance, two Oxycodone/Acetaminophen tablets were documented as wasted after being dropped, but there was no evidence of a required witness or second signature for either event. The nurse involved confirmed the lack of a witness signature, and the DON verified that all nurses were expected to have a witness and document accordingly when wasting narcotics. These failures were observed on two separate medication carts and involved two different residents.
Failure to Provide Sufficient Fluids for Hydration
Penalty
Summary
The facility failed to provide sufficient fluids to maintain adequate hydration for one resident, as required by facility policy and the resident's care plan. Multiple observations over several days revealed that the resident did not have a water pitcher or any other fluid for hydration at the bedside, despite being awake and alert in the room. The facility's policy mandates that a water pitcher with water and ice be placed at the bedside of all residents unless contraindicated, and that nursing assistants offer fluids every two hours unless restricted. Review of the resident's medical record showed no fluid restrictions, and both the CNA and LPN confirmed that the resident should have had a water pitcher available. The resident in question had a history of Alzheimer's, mild protein-calorie malnutrition, chronic ulcer, peripheral vascular disease, anxiety disorder, dysphagia, osteoarthritis, and a history of urinary tract infections. The care plan included interventions to encourage fluid intake, especially while on antibiotic therapy for a UTI, which required a minimum fluid intake per facility guidelines. Documentation of fluid offers was inconsistent and did not meet the every-two-hour standard. Staff interviews confirmed the absence of a water pitcher and acknowledged that the resident should have had one at the bedside.
Delayed Appropriate Treatment for UTI
Penalty
Summary
The facility failed to provide timely and appropriate treatment for a resident with a urinary tract infection (UTI). The resident, who had a history of UTIs and other medical conditions such as unspecified dementia and overactive bladder, was initially prescribed Bactrim DS after a urinalysis indicated elevated leukocytes and bacteria. However, a subsequent culture and sensitivity test revealed that the pathogen, Escherichia Coli, was resistant to Bactrim DS and other antibiotics, and was susceptible only to Ertapenem. Despite this, the resident continued to receive inappropriate antibiotics until the correct treatment was administered much later. The delay in appropriate treatment was due to a failure in the facility's process for handling lab results. Although the culture and sensitivity results were available and stamped by the facility shortly after being reported, they were not acted upon until much later. Interviews with facility staff revealed that lab results are faxed to the facility and can be accessed via computer, but there was a breakdown in communication and follow-up, leading to the resident not receiving the correct antibiotic in a timely manner.
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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 Alexandria
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Belle Grande Nursing And Rehabilitation Center | 1.7 mi | ★★★★★ | 9 | 0 |
| The Summit | 2.4 mi | ★★★★★ | 10 | 0 |
| Regency House Of Alexandria | 2.5 mi | ★★★★★ | 16 | 0 |
| Matthews Memorial Health Care Center | 2.8 mi | ★★★★★ | 10 | 0 |
| Legacy Nursing At St. Christina | 4.6 mi | ★★★★★ | 23 | 0 |
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