Average — CMS composite of the measures below.
The next survey window likely opens 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 Care One At Lexington during CMS and state inspections, most recent first.
Failure to deliver resident mail on Saturdays. The facility policy stated residents could send and receive personal mail confidentially and that mail and packages would be delivered within 24 hours, including Saturday deliveries. During a resident group meeting, residents said mail was only delivered Monday through Friday, and the Activities Director confirmed he typically delivered mail only on weekdays and held Saturday USPS mail until Monday. The Administrator stated mail delivery should not be different on Saturdays.
Unclean and Damaged Resident Unit Environment: The facility failed to maintain a clean, comfortable, and homelike environment on one unit. Surveyors observed stained and damaged surfaces, including stained flooring, ceiling tiles, doors, furniture, window shades, dirty overbed tables, leaking sinks with basins catching water, torn fall mats with exposed foam, and other visible wear and debris in multiple resident rooms.
Bed Did Not Fit Resident Appropriately: A resident with stroke, vascular dementia, reduced mobility, and moderate cognitive impairment was repeatedly observed resting with the feet and ankles hanging off the end of the bed. Staff said the resident was tall and had been sliding down in bed for months, with one nurse stating the feet had hung over the edge for about a year. A unit manager had requested a longer bed, but the resident remained in the same bed during survey observations.
Failure to Process Resident Grievance for Missing Robe: A cognitively intact resident reported a missing bathrobe and said an UM told him/her there was nothing she could do, and no grievance form was offered. The grievance log had no entry for the missing item, and the UM later acknowledged she heard about the issue through the HCP but did not complete a grievance form; the Administrator said a grievance should have been completed.
Wrong transdermal patch removed during med pass. An RN removed a peach-colored clonidine patch from a resident’s arm, believed it was an old nicotine patch, discarded it, and then applied a nicotine patch. The resident had orders for both clonidine and nicotine patches, and staff later confirmed the removed patch was clonidine, while the RN stated she did not realize the resident had a clonidine patch ordered.
Portable Heater Left in Resident Room: A resident with intact cognition and diagnoses including DM, chronic pain, and anemia had a portable oil-filled radiator heater observed next to the bed, with an electric power strip nearby. Facility policy prohibited portable space heaters in resident areas, and staff interviews confirmed the heater was not allowed in resident rooms. The resident said a family member had brought the heater in for use when the AC was too cold, but it was no longer needed once the building heat was on.
Food items were not stored appropriately in the main kitchen reach-in refrigerator. The surveyor observed undated and unlabeled sandwiches and pudding cups, along with sandwiches labeled with use-by dates that had already passed. The FSD stated that all items should be dated and labeled in the refrigerator, that the pudding cups had been used for the prior night's dinner meal, and that sandwiches should be discarded after three days.
Incomplete and Inaccurate Resident Medical Records: The facility failed to keep complete and accurate charting for two residents. One resident with heart disease and anxiety disorder had ordered weekly skin checks that were not documented as completed or refused, despite bruising being observed and the resident being unsure whether the skin had been assessed. Another resident with COPD and a prior cerebrum hemorrhage had scabies treatment orders that were not accurately transcribed into the MAR/TAR, and a separate itch treatment order was nonspecific even though nursing staff signed off on it.
The facility failed to maintain a homelike environment, with surveyors observing cracked paper towel holders, sagging ceiling tiles, worn furniture, and non-functional hand sanitizer units across several units. Interviews revealed lapses in reporting and addressing maintenance issues, as the Maintenance Director was unaware of some problems, and the Administrator emphasized the need for reporting broken equipment.
The facility failed to follow food service safety standards by allowing a cook to handle ready-to-eat baked potatoes with bare hands, violating the policy that requires gloves for such tasks. The Food Service Director acknowledged the error and indicated that the affected potatoes must be discarded.
The facility failed to ensure accurate documentation and compliance with physician orders for three residents. One resident was documented as wearing compression stockings that were never applied, another was not consistently provided with required heel protectors, and a third received a lidocaine patch without a specified application site. Staff were unaware of these orders, leading to inaccurate records and non-compliance.
The facility failed to follow infection control procedures, including improper cleaning of blood glucose meters, inadequate use of personal protective equipment, and expired hand sanitizers. Two nurses did not clean glucometers as per policy, and staff did not wear gowns or gloves in rooms requiring enhanced precautions. A CNA failed to perform proper hand hygiene, and expired hand sanitizers were found in multiple locations.
The facility failed to secure hallway handrails on the [NAME] and Minuteman units, with surveyors observing detached end caps and exposed screws. Maintenance staff acknowledged ongoing issues with loose handrails, and the facility's reporting system lacked records of these deficiencies. The Administrator expected immediate reporting and fixing of such issues, indicating a communication gap in maintenance processes.
A resident with cerebral palsy, Parkinson's disease, and tremors was observed struggling to eat meals without assistance, resulting in spills and undignified dining conditions. Despite the resident's visible difficulties and expressed need for help, staff did not check in or offer assistance during meals, leading to a deficiency in providing a dignified dining experience.
The facility failed to accurately complete MDS assessments for two residents, leading to discrepancies in recorded assistance levels and discharge information. One resident's MDS did not match the documented assistance needs for daily activities, while another's discharge location was incorrectly recorded. These inaccuracies were acknowledged by the MDS nurse, indicating a failure in proper documentation.
The facility failed to implement physician orders and develop comprehensive care plans for residents, leading to deficiencies in care. A resident with congestive heart failure did not receive prescribed compression stockings, while another with diabetes did not have heel protector boots applied. A resident with cerebral palsy lacked a care plan for eating assistance, and another with a history of falls was not supervised adequately, despite being at risk. Staff were often unaware of these orders and care needs.
A resident was prescribed ascorbic acid ER for wound healing, but the facility did not stock this form. Nursing staff administered the medication 25 times without clarifying the order with the physician. The Unit Manager and DON acknowledged the need for clarification, highlighting a failure to adhere to medication administration policies.
A resident with cerebral palsy and malnutrition required moderate assistance with eating due to tremors and coordination issues. Despite this, the resident's care plan lacked details on the necessary assistance, and they were observed struggling to eat without staff help. Interviews revealed a communication gap between therapy and nursing departments, as therapy assessments were not accessible to nursing staff, leading to inadequate care.
A resident with a worsening wound condition did not receive appropriate wound care due to the facility's failure to obtain necessary treatment orders after a wound vac was placed on hold. Despite the resident's need for continued care, there were no documented orders for the use of Santyl or dressing changes, leading to confusion among nursing staff and inadequate wound management.
The facility failed to provide necessary treatment and services for pressure ulcers for two residents. One resident was admitted with a known deep tissue pressure injury but did not receive timely treatment or an air mattress. Another resident had an air mattress set incorrectly, contrary to physician orders, leading to inadequate pressure ulcer management. The facility's policies on pressure ulcer care were not followed, resulting in deficiencies in care.
A resident with a tracheostomy did not receive proper respiratory care, as their equipment was found soiled and improperly stored, leading to a deficiency. The RT was responsible for equipment changes but lacked specific orders, resulting in inconsistent maintenance. The DON confirmed the need for weekly changes, which were not adhered to.
The facility failed to ensure nursing staff were competent in medication administration, leading to deficiencies in care for residents. A nurse improperly used an insulin pen and administered enoxaparin without following guidelines, resulting in incorrect dosing and increased infection risk. Additionally, agency nurses lacked completed medication administration competencies, with no staff educator to oversee training.
A resident did not receive modafinil as ordered by the physician due to the facility's failure to follow its policy on unavailable medications. Despite the resident's report of inconsistent availability and lack of alternatives, staff interviews revealed uncertainty and inaction regarding the medication's unavailability.
The facility failed to address pharmacist recommendations for two residents. One resident's Depakote monitoring was not implemented, and another's Trazodone prescription lacked a stop date despite physician approval. Staff interviews confirmed these oversights in medication management.
Two residents in an LTC facility experienced significant medication errors related to insulin administration. One resident did not receive insulin before breakfast as ordered, leading to hyperglycemia, while another received an inaccurate dose due to a failure to prime the insulin pen. These errors were due to staff not following physician orders and medication protocols.
The facility failed to properly store and label medications, as observed in an unlabeled medication cup in a cart and an unlocked treatment cart with unattended supplies. Additionally, a vial of Tuberculin was incorrectly labeled with an expiration date beyond the manufacturer's 30-day guideline.
A facility failed to obtain a resident's Depakote serum drug level as ordered by the physician, resulting in a 16-month lapse in testing. The resident, with major depression and traumatic brain injury, had orders for biannual Depakote level checks, but the facility did not document these tests. Staff interviews revealed scheduling errors in the electronic health record and a lack of confirmation for lab slips, leading to the oversight.
A resident with celiac disease was served gluten-containing foods due to a failure in the facility's tray ticket system, which did not reflect the resident's gluten allergy. The resident's medical record indicated a gluten allergy, but the system error led to the resident being served pasta, bread, and gravy containing gluten, contrary to their dietary needs.
The facility failed to post daily nurse staffing information as required, omitting the facility census and total number and hours for RNs, LPNs, and CNAs. Observations showed outdated and incomplete postings, and interviews revealed staff were unaware of the full requirements. The Director of Nursing and Administrator acknowledged the need for compliance.
The facility did not notify the State Agency of a change in the Director of Nursing (DON) position as required by policy. The new DON had been in the role for over a month, but the facility failed to submit the necessary notice to the Health Care Facility Reporting System. The Administrator acknowledged the oversight, admitting that the change was not reported despite the policy requiring notification at least fourteen days prior to the change.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure resident rights were maintained by not delivering U.S. Postal Service mail on Saturdays. The facility policy, revised May 2017, stated that residents may communicate privately and may send and receive personal mail, email, and other electronic forms of communication confidentially, and that mail and packages would be delivered to residents within 24 hours of delivery on premises or to the facility's post office box, including Saturday deliveries. During a resident group meeting attended by 17 residents, three active participants stated that mail was delivered Monday through Friday and that no staff member delivered mail on Saturday, even though they received U.S. mail on Saturdays outside the facility. The Activities Director stated he was responsible for delivering resident mail, typically at the end of the day Monday through Friday, and that mail delivered on Saturday by the U.S. Postal Service was delivered on Mondays. The Administrator stated that mail delivery should not be any different and that mail should be delivered on Saturdays.
Unclean and Damaged Resident Unit Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment on one unit. Review of the facility policy titled Homelike Environment, dated February 2021, indicated that residents are to be provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. On the [NAME] Unit, the surveyor observed multiple environmental concerns, including red stains on a radiator and chair, a large bowing stained ceiling tile, gouges and scrapes in bathroom doors, deep scratches in flooring near a bed, stained flooring near toilets, stained window shades, broken and missing drawer handles on nightstands and dressers, visibly dirty overbed tables, peeling laminate on a dresser, long black scuff marks along closet doors, and torn or visibly soiled fall mats with exposed foam. In one room, a basin was catching water from a leaking sink faucet, and in another, a basin was catching water from a sink leak with a towel on the floor wrapped around the toilet.
Bed Did Not Fit Resident Appropriately
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident by not providing a bed that fit the resident appropriately. The resident was admitted in July 2024 with diagnoses including stroke, vascular dementia, and reduced mobility. The Minimum Data Set indicated the resident was moderately cognitively impaired with a BIMS score of 8 out of 15, dependent on staff for positioning and transfers, and 76 inches tall. The facility policy stated that resident needs and preferences, including adaptive devices and physical environment modifications, are to be evaluated on admission and reviewed ongoingly. During survey observations, the resident was seen resting in bed with the ankles and feet hanging off the end of the bed on multiple occasions. The resident stated the feet and ankles had been sliding off the edge of the bed forever and said nobody cared when asked whether staff were aware. Staff interviews indicated the resident had been tall and sliding down in bed for about a year, with the feet hanging off the edge for an ongoing period of months. A unit manager said a request for a longer bed had been sent to maintenance a couple of weeks earlier and showed a text message dated 12/4/25 requesting the longer bed. The maintenance director said he was not sure when the request was placed but would obtain a longer bed that day, and a consultant nurse stated that if a resident's bed does not fit appropriately, a new one should be provided.
Failure to Process Resident Grievance for Missing Robe
Penalty
Summary
The facility failed to follow its grievance process for a cognitively intact resident who reported a missing bathrobe. The resident, admitted with diagnoses including altered mental status and essential hypertension, told staff that the robe had gone missing from the room and stated that Unit Manager #2 responded that there was nothing she could do about it. The resident also reported that staff did not offer a grievance form to complete. Review of the grievance book/log did not show any grievance related to missing items for the resident. Unit Manager #2 stated she had heard about the missing robe about a month earlier through the resident’s health care proxy and acknowledged that she did not complete a grievance form, although she said she should have. The Administrator stated she reviews all grievances and was not aware of any concerns for the resident, and agreed that a grievance should have been completed after the resident reported the missing robe.
Wrong transdermal patch removed during medication pass
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for one resident when Nurse #4 removed the wrong transdermal patch during a medication pass observation. Resident #55 was admitted with diagnoses including urinary retention, alcohol dependence, hypertension, and chronic obstructive pulmonary disorder, and had moderate cognitive impairment with a BIMS score of 12 out of 15. Physician orders included a clonidine transdermal patch weekly for hypertension and a nicotine transdermal patch daily for smoking cessation. During the medication administration observation, Nurse #4 removed a peach-colored patch from the resident’s left arm, crumpled it, and discarded it, then applied a clear nicotine patch to the right chest wall. When asked, Nurse #4 stated she had removed the old nicotine patch. The surveyor later reobserved the removed peach-colored patch and confirmed it was labeled clonidine 0.2 mg/day. Later review and interview found that the clonidine patch documented as applied the prior day could not be located, and Nurse #4 stated she was unaware she had removed the clonidine patch and did not realize the resident had a clonidine patch ordered. The Facility Educator and a Nurse Consultant stated the patch should have been verified before removal.
Portable Heater Left in Resident Room
Penalty
Summary
The facility failed to identify and eliminate a known accident hazard in Resident #46’s room when a portable oil-filled radiator heater was left next to the resident’s bed, with an electric power strip also observed nearby. The facility policy titled, Electrical Appliances, revised January 2019, stated that portable space heaters are not allowed in resident areas. Resident #46 was admitted in December 2024 and had diagnoses including diabetes, chronic pain, and anemia; the most recent MDS dated 9/26/25 showed intact cognition with a BIMS score of 15 out of 15. On 12/22/25 at 8:16 A.M., the surveyor observed the heater in the room. During interviews, the Maintenance Supervisor stated that electric heaters are not allowed in resident rooms and said the heater would be removed immediately, noting the risk of fire. He later said the heater had already been removed by another staff member. Unit Manager #3 stated she had removed the heater when she noticed it in the room and said she had not seen it there before. CNA #2 said she had never seen the heater in the room before. Resident #46 stated that his/her son had brought in the heater for use when the air conditioning had been too cold, but that it was no longer needed since the heat had been turned on in the building. The Administrator stated she was not aware the heater was in the resident’s room and confirmed the facility policy prohibiting electric heaters in resident rooms due to fire risk.
Improper Food Labeling and Storage in Kitchen Refrigerator
Penalty
Summary
Food items were not stored appropriately in the reach-in refrigerator in the main kitchen. During the initial kitchen walk-through, the surveyor observed two sandwiches that were undated and unlabeled, one chicken sandwich labeled with a use-by date of 12/21/25, 19 containers of pudding that were undated and unlabeled, one chicken salad sandwich labeled with a use-by date of 12/19/25, and one peanut butter sandwich labeled with a use-by date of 12/15/25. The facility policy titled Food Receiving and Storage stated that all foods stored in the refrigerator or freezer are to be covered, labeled, and dated, and that refrigerated foods are to be labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded. During interview, the Food Service Director stated that all items should be dated and labeled in the refrigerator and that the pudding cups had been used for the previous night's dinner meal, and sandwiches should be discarded after three days.
Incomplete and Inaccurate Resident Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents. One resident, admitted with diagnoses including heart disease and anxiety disorder and identified as at risk for skin breakdown, had a physician order for a weekly full skin check every Saturday evening. The record showed the skin checks were not completed on two ordered dates, and there was no documentation in the medical record showing staff attempted the assessments on those dates. During observation, bruising was noted on the resident’s forearms and wrists, and the resident said he/she was unsure whether the bruises were from a fall at home or occurred at the facility and did not know whether staff had assessed the skin since admission. A written statement from the assigned nurse said the resident was very anxious and refused the skin checks, but the statement did not show that the refusals were documented in the medical record. A second resident, re-admitted with diagnoses including COPD and traumatic hemorrhage of the cerebrum and assessed as moderately cognitively impaired, had dermatology orders for scabies treatment that included ivermectin and permethrin cream. The physician orders, MAR, and TAR did not show that permethrin was applied, and the Infection Preventionist stated the treatment had been given but was not appropriately transcribed into the clinical record. In addition, a current physician order directing staff to apply something to the whole body for itch did not specify what was to be applied, yet nursing staff signed off on the order. The Unit Manager stated the order should have specifically identified the treatment and that nursing staff should have clarified it with the physician.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to ensure a homelike environment across several units, as observed by surveyors. On the [NAME] unit, issues included cracked plastic paper towel holders in multiple rooms and the hallway men's room, sagging and broken ceiling tiles in several rooms, worn dressers, and a broken bathroom wall. On the [NAME] unit, surveyors noted cracks in the wallpaper, a call light device hanging by an electrical cord, and a closet door falling off its hinges. The Minuteman unit had dressers with missing laminate, chipped wood and scratched paint on door trims, sagging ceiling tile trim, and non-functional hand sanitizer units. Interviews with the Maintenance Director revealed that while there is a maintenance tracking program in place, not all issues were reported by staff, leading to some being unaddressed. The Maintenance Director was aware of some issues but not others, such as the broken paper towel holders and bathroom wall. The Administrator confirmed that broken or non-functional equipment should be reported and addressed, indicating a lapse in communication and reporting within the facility's maintenance processes.
Improper Handling of Ready-to-Eat Food
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by allowing staff to handle ready-to-eat food with their bare hands. During a tray line observation, a cook was seen using his bare hands to transfer four ready-to-eat baked potatoes from the steam table onto plates intended for residents. This action was in direct violation of the facility's policy, which prohibits contact between food and bare hands and mandates the use of gloves when handling ready-to-eat food. The Food Service Director confirmed that the cook should not have touched the potatoes with his bare hands and stated that all the potatoes touched by the cook must be discarded.
Inaccurate Documentation and Order Compliance Issues
Penalty
Summary
The facility failed to ensure accurate documentation of the clinical records for three residents. For one resident with congestive heart failure and bilateral leg edema, the facility documented that compression stockings were applied daily, despite observations and staff interviews indicating that the resident never wore them. The CNA and nurse responsible for the resident were unaware of the physician's order for the stockings, and the Director of Nurses confirmed that the documentation was inaccurate. Another resident with diabetes and peripheral vascular disease was supposed to wear heel protector boots at all times, as per physician's orders. However, observations revealed that the resident was often without the boots, and staff interviews indicated a lack of awareness of the order. The resident reported that the left boot was lost and not replaced properly, leading to its non-use for several months. The Director of Nurses acknowledged that the physician's orders were not being followed. For a third resident with chronic pain, the facility failed to obtain a complete physician's order for a lidocaine patch, which lacked a specified application site. The nursing staff administered the patch without documenting the location, and the Unit Manager confirmed the order was incomplete. The Director of Nursing stated that the order should have included a location for application.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection control procedures, as evidenced by multiple observations and interviews. Two nurses did not clean blood glucose meters according to the facility's policy. One nurse placed a glucometer back into its case without cleaning it after use, while another used an alcohol wipe instead of a germicidal wipe due to unavailability. The Director of Nursing confirmed that the glucometers should be cleaned with germicidal wipes after each use. Additionally, staff did not wear complete personal protective equipment in rooms requiring enhanced barrier precautions. A nurse was observed taking vital signs from a resident receiving enteral nutrition without wearing a gown or gloves and did not disinfect the equipment between uses. The Director of Nursing stated that residents on enteral nutrition should be on enhanced barrier precautions, and staff should wear gloves and gowns during high-contact activities. The facility also failed to ensure proper hand hygiene and glove use. A CNA was seen wearing gloves in the hallway and did not wash hands after removing them, potentially contaminating surfaces. Furthermore, expired hand sanitizer was found in multiple wall-mounted units throughout the facility. The Director of Housekeeping and the Administrator acknowledged that expired hand sanitizer should not be in use and should be replaced by housekeeping staff.
Facility Fails to Secure Hallway Handrails
Penalty
Summary
The facility failed to ensure that hallway handrails were securely fastened on the [NAME] and Minuteman units. Observations by the surveyor revealed multiple instances of detached handrail end caps and exposed metal screws in various locations, including near rooms 223-224, the sprinkler room, and the dining room. These deficiencies were noted during a series of observations conducted on 12/27/24 and 12/30/24. Interviews with maintenance staff revealed that the issue of loose handrails was ongoing, with the Maintenance Director acknowledging that he had noticed missing end caps about a week prior but had not yet ordered replacements. The facility's online TELS program, which is used to report maintenance issues, did not contain any records of the broken or missing handrails. Additionally, a preventative maintenance worksheet indicated that handrails needed fixing but lacked a completion date. The Administrator expressed an expectation that such issues should be reported and addressed immediately, highlighting a gap in communication and follow-up within the facility's maintenance processes.
Failure to Provide Dignified Dining Experience for Resident with Eating Difficulties
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident with multiple medical conditions, including cerebral palsy, Parkinson's disease, and tremors, which affect their ability to eat independently. The resident, who has moderately impaired cognition, was observed struggling to eat meals without assistance. During breakfast, the resident attempted to eat scrambled eggs using a weighted utensil but was unable to gather food onto the utensil due to tremors. The resident resorted to using their mouth and hand to eat directly from the plate, resulting in food spilling onto their clothing and the floor. Similarly, during lunch, the resident had difficulty bringing a juice cup to their mouth, causing spills. Throughout both meals, staff did not check in or offer assistance, despite the resident's visible struggle and expressed desire for help. Interviews with staff revealed that the resident is typically set up for meals but sometimes requires assistance due to their tremors. Staff members acknowledged that they should be offering help and checking in during meals to ensure the resident can eat. The Director of Nursing confirmed that staff should not leave the resident without ensuring they can access and consume their meal, and they should encourage and offer assistance as needed. However, during the observed meals, these actions were not taken, leading to the deficiency in providing a dignified dining experience.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for two residents, leading to discrepancies in the recorded levels of assistance required. Resident #4, who was admitted with diagnoses including dementia, bipolar disorder, and anxiety disorder, had inconsistencies between the facility's Documentation Survey Report and the MDS. The Documentation Survey Report indicated that Resident #4 required substantial to maximum assistance for eating, oral hygiene, and upper body dressing, while the MDS inaccurately recorded these needs as requiring only supervision or partial assistance. This discrepancy was acknowledged by MDS Nurse #1, who confirmed that the MDS should reflect the daily documentation completed by the Certified Nurse's Aides (CNAs). Similarly, Resident #139, admitted with conditions such as cellulitis, diabetes, and malnutrition, was discharged home with medications and family, as noted in the progress notes. However, the MDS inaccurately documented the discharge location as an acute care hospital. MDS Nurse #1 admitted that the MDS was not coded correctly and should have accurately reflected the resident's actual discharge location. These inaccuracies in the MDS assessments highlight a failure in ensuring that the residents' needs and discharge information were correctly documented, as per the facility's documentation and procedures.
Failure to Implement Care Plans and Physician Orders
Penalty
Summary
The facility failed to implement physician orders and develop comprehensive care plans for several residents, leading to deficiencies in care. For one resident with chronic congestive heart failure and bilateral leg edema, the facility did not implement the physician's order for compression stockings. Despite documentation indicating that the stockings were applied and removed daily, observations and staff interviews revealed that the resident was not wearing them, and staff were unaware of the order. Another resident with diabetes and peripheral vascular disease did not receive the prescribed heel protector boots. Observations showed the resident's heels resting on the mattress without the boots, and staff interviews confirmed a lack of awareness of the physician's order. The resident reported that the boots were not applied due to a lost boot and an ill-fitting replacement, leading to staff discontinuing their application. Additionally, a resident with cerebral palsy and malnutrition did not have a care plan for eating assistance, despite requiring moderate assistance due to tremors. Observations showed the resident struggling to feed themselves without staff assistance, resulting in significant food spillage. Lastly, a resident with cerebral palsy and a history of falls did not have a comprehensive falls care plan. The resident was observed sliding out of their wheelchair without supervision, and staff interviews indicated a lack of awareness of the need for continuous supervision, despite the resident's known fall risk.
Failure to Clarify Medication Order for Resident
Penalty
Summary
The facility failed to meet professional standards of practice for a resident due to a lack of clarification regarding a physician's order for ascorbic acid extended release (ER) oral capsule. The resident, who was admitted with diagnoses including diabetes, chronic pain, and colitis, was prescribed ascorbic acid ER for wound healing. However, the facility did not stock this form of the medication. Despite this, nursing staff documented administering the medication 25 times over a period of 11 days without clarifying the order with the physician or adjusting to the available form of the medication. During the survey, it was observed that a nurse was unaware of the ascorbic acid ER form and noted that the pharmacy had not delivered it. The Unit Manager and Director of Nursing both acknowledged that the nursing staff should have clarified the order with the physician and adjusted to the form of the medication on hand. This oversight indicates a failure to adhere to the facility's medication administration policy, which requires verification and clarification of medication orders to ensure safe and appropriate administration.
Failure to Assist Resident with Eating Due to Communication Gap
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident diagnosed with cerebral palsy and malnutrition. The resident, who was cognitively intact, required moderate assistance with eating due to impairments in balance, fine motor coordination, and strength, as well as a bilateral upper extremity tremor. Despite these needs, the resident's care plan did not outline the level of assistance required for eating, and the resident was observed struggling to feed themselves without staff assistance. Observations by the surveyor revealed that the resident was left alone during meal times, resulting in significant portions of food being dropped and not consumed. This lack of assistance was consistent over multiple days, with the resident visibly struggling to manage eating independently due to their tremors. Interviews with the resident confirmed their need for assistance, as they expressed difficulty in keeping food on the spoon due to worsening tremors. Interviews with facility staff, including a nurse, occupational therapist (OT), and the Director of Nursing (DON), highlighted a communication gap between the therapy and nursing departments. The OT had assessed the resident's need for assistance and expected this to be reflected in the care plan, but the information was not accessible to nursing staff due to being stored in a separate software system. The DON acknowledged that the care plan should have included the level of assistance required, as determined by the OT, but this was not implemented, leading to the deficiency in care provided to the resident.
Failure to Obtain Wound Care Orders for Resident
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident with a worsening wound condition. The resident, who was admitted with osteomyelitis, diabetes, and peripheral vascular disease, had a wound vac placed on hold due to maceration and worsening of the wound. Despite the need for continued wound care, the facility did not obtain new wound care orders for five days after the wound vac was stopped. During this period, the resident reported that nursing staff applied Santyl daily, but there were no documented orders for this treatment in the resident's medical records. The resident expressed concerns that nursing staff were unsure of the appropriate wound care procedures due to the lack of orders. Interviews with the unit manager and the director of nursing confirmed that there were no orders for the use of Santyl or for dressing changes while the wound vac was on hold, which should have been obtained. The resident's medical records and treatment administration records did not include necessary orders for the period when the wound vac was not in use, leading to a lapse in proper wound care management.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for pressure ulcers for two residents, leading to deficiencies in care. Resident #441 was admitted with a known deep tissue pressure injury (DTPI) on the coccyx, but the facility did not place an order for treatment or monitoring of the wound upon admission. Despite the presence of a dressing on the wound, nursing staff were unaware of the injury, and no treatment orders were initiated until after the surveyor's intervention. The resident was also not provided with an air mattress until three days post-admission, contrary to the physician's expectations. Resident #119, who had severe cognitive impairment and a history of pressure injuries, was observed with an air mattress set incorrectly at 200 pounds, despite physician orders specifying a setting of 150 pounds. The resident's care plan and physician's orders were not consistently implemented, leading to the resident being at risk for further skin breakdown. Observations revealed that the resident's buttocks were red, macerated, excoriated, and had open areas, indicating inadequate pressure ulcer management. The facility's policies on pressure ulcer care and support surface guidelines were not adhered to, resulting in a lack of appropriate interventions for residents at risk of skin breakdown. The Director of Nursing acknowledged that the air mattress settings should have been adjusted according to the physician's orders, and that treatment orders should have been in place for Resident #441's DTPI upon admission.
Failure to Maintain Clean Respiratory Equipment for Resident with Tracheostomy
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with a tracheostomy, leading to a deficiency in maintaining the cleanliness and sanitation of the resident's respiratory equipment. The resident, who was admitted with diagnoses including malignant neoplasm of the mouth, dysphagia, and COPD, required tracheostomy care as indicated in their plan of care. During an observation, the surveyor noted that the resident's tracheostomy mask and respiratory equipment were visibly soiled with dried secretions and were improperly stored on a cart with various other items, which could lead to potential contamination and infection. Interviews with facility staff, including a nurse, unit manager, and respiratory therapist (RT), revealed that the RT was responsible for managing the respiratory equipment. However, the RT did not have specific physician's orders for changing the equipment and stated that changes were typically made weekly, or sooner if necessary. The Director of Nursing confirmed that the equipment should be changed weekly and dated accordingly. The observations and interviews highlighted a lapse in maintaining the cleanliness and timely replacement of respiratory equipment, contributing to the deficiency.
Nursing Competency Deficiencies in Medication Administration
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies to provide adequate care for residents, as evidenced by multiple deficiencies observed during the survey. For one resident with diabetes and other medical conditions, a nurse was observed using an insulin pen without priming it, resulting in an incorrect insulin dose. Additionally, the nurse did not clean the insulin pen with alcohol before use, increasing the risk of infection. The nurse admitted to being unaware of the need to prime the pen or clean it with alcohol, and the Director of Nursing confirmed that the nurse should have been competent in these procedures. In another instance, the same nurse demonstrated a lack of competency in administering enoxaparin, a medication used to thin blood. The nurse struggled to locate and prepare the medication, and ultimately administered it without cleaning the injection site, which led to immediate bruising. The nurse also mishandled the syringe, walking with an exposed needle, which posed a risk to staff and residents. The Director of Nursing acknowledged that the nurse should have been competent in administering enoxaparin but was not. Furthermore, the facility failed to ensure that agency nursing staff were adequately trained and demonstrated competency in medication administration techniques. The surveyors identified multiple concerns, including the failure to clean a glucometer and improper use of an insulin pen. A review of staff education files revealed that none of the nurses with identified concerns had completed medication administration competencies. The facility lacked a staff educator to oversee the completion of required orientation packets for agency nurses, contributing to the deficiencies observed.
Failure to Provide Routine Medication to Resident
Penalty
Summary
The facility failed to provide routine medications to a resident, specifically modafinil, as ordered by the physician. The resident, who was admitted with diagnoses including anxiety, depression, ADHD, and dysphagia, reported that the nursing staff did not consistently have the medication available and did not offer any alternatives when it was unavailable. The facility's policy on unavailable medications requires the pharmacy to notify nursing staff when medications are unavailable and suggest alternatives, while nursing staff are to inform the attending physician and obtain new orders. However, these steps were not followed, leading to the resident missing multiple doses of modafinil over several days. Interviews with facility staff revealed a lack of clarity and action regarding the unavailability of the medication. The Unit Manager was unsure why the medication was not administered, suggesting it might have been back-ordered, while the Director of Nursing acknowledged that the medication should have been available and that alternative methods could have been used to obtain it. Despite the facility's policy, there was no evidence that the nursing staff notified the physician or sought alternative medications, resulting in a failure to meet the resident's pharmaceutical needs.
Failure to Implement Pharmacist Recommendations
Penalty
Summary
The facility failed to address recommendations from the Monthly Medication Reviews (MMR) conducted by the consultant pharmacist for two residents. For Resident #14, who was admitted with diagnoses including major depression and traumatic brain injury, the facility did not act on the pharmacist's recommendation to monitor Depakote levels and liver function tests. Despite the pharmacist's note dated 11/6/24, the recommendation was not addressed, and the Unit Manager did not recall receiving the MMR for November 2024. For Resident #29, who was admitted with conditions such as osteomyelitis, diabetes, and peripheral vascular disease, the facility did not implement the pharmacist's recommendation regarding the Trazodone prescription. The pharmacist noted on 12/8/24 that the Trazodone order needed a duration, and the attending physician agreed to a 14-day extension. However, the order was not updated with a stop date, and the Unit Manager was unsure why the MMR was not implemented by nursing. Interviews with facility staff, including the Director of Nursing, confirmed that the MMRs should have been addressed and implemented. The failure to act on these recommendations indicates a lapse in the facility's medication management processes, impacting the care provided to the residents involved.
Medication Errors in Insulin Administration
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors. For Resident #29, the nursing staff did not administer insulin as per the physician's order. The resident, who was admitted with conditions including diabetes, reported not receiving insulin before breakfast, as required. The nurse responsible was unaware of the resident's diabetic status and failed to check blood sugar levels or administer insulin on time. This resulted in the resident experiencing symptoms of hyperglycemia, with a blood sugar level of 345 recorded after breakfast, nearly four hours past the scheduled insulin administration time. For Resident #391, the nursing staff failed to prime the insulin pen injector before administering insulin, leading to an inaccurate dose. The resident, who was admitted with diabetes and other conditions, was observed receiving insulin glargine without the pen being primed. The nurse involved was not aware of the need to prime the insulin pen, which is a critical step to ensure the correct dosage is delivered. This oversight was acknowledged by the Director of Nursing, who confirmed that the pen should have been primed to ensure the resident received the correct dose. Both incidents highlight a failure to adhere to established medication administration protocols, as outlined in the facility's policies and the manufacturer's guidelines for insulin pen use. These deficiencies were identified through observations, interviews, and record reviews conducted by the surveyors, indicating lapses in the nursing staff's adherence to physician orders and medication administration procedures.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals, as observed in several instances. On the [NAME] Unit, a medication cart was found to contain an unlabeled medication cup with 10 pills. Nurse #2 admitted to placing the cup in the cart after running out of an over-the-counter medication and leaving the unit to retrieve more. This indicates a lack of awareness regarding the prohibition of storing unlabeled medications in the cart. Additionally, a treatment cart was found unlocked and unattended between resident rooms, with wound supplies left on top. Nurse #1 acknowledged that the cart should have been locked and supplies should not have been left unattended. In the medication storage room, an opened vial of Tuberculin, Purified Protein Derivative, was found with an incorrect expiration date. The vial was labeled with an open date of 12/28/24 and an expiration date of 3/22/25, despite manufacturer instructions to discard it 30 days after opening. Nurse #2 was unsure of the correct duration, while Unit Manager #2 confirmed the 30-day guideline. The Director of Nurses reiterated the importance of proper dating. These observations highlight lapses in adherence to medication storage and labeling protocols.
Failure to Obtain Depakote Levels as Ordered
Penalty
Summary
The facility failed to ensure that laboratory services were provided for a resident, specifically in obtaining the Depakote serum drug level as ordered by the physician. The resident, who was admitted with diagnoses including major depression and traumatic brain injury, had a physician's order for Depakote level checks every six months. However, the facility did not document the completion of these tests in accordance with the physician's orders and the resident's plan of care. The last recorded Depakote level was from August 2023, and no further results were documented, indicating a lapse of 16 months without the required testing. Interviews with facility staff revealed that the orders for the Depakote levels were not scheduled correctly in the electronic health record, and there was a failure to confirm that lab slips were in place for the tests. Nurse #4 admitted to not confirming the completion of the Depakote levels, and Unit Manager #3 acknowledged that nursing should have followed the physician's orders. The Director of Nursing also confirmed that the Depakote levels should have been obtained as ordered.
Failure to Accommodate Gluten Allergy for Resident with Celiac Disease
Penalty
Summary
The facility failed to provide food that accommodated the allergies and dietary needs of a resident with celiac disease, a condition that requires a strict gluten-free diet. Despite the resident's medical record clearly indicating a gluten allergy and an active diagnosis of celiac disease, the facility served the resident food containing gluten. This included pasta made from semolina and durum wheat, as well as bread and gravy thickened with flour, all of which were observed being consumed by the resident during meal times. The deficiency was attributed to a failure in the facility's tray ticket system, which did not reflect the resident's gluten allergy due to an incorrect categorization upon admission. The Food Service Director confirmed that the system should have automatically populated the allergy information from the resident's electronic health records, but it did not. Consequently, the resident was served gluten-containing foods, contrary to their dietary restrictions, as confirmed by both the cook and the Registered Dietitian.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the regulatory requirement to post daily nurse staffing information at the start of each shift. Specifically, the facility did not consistently post the facility census, total number, and hours for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nurse Aides (CNAs) as required. Observations by the surveyor on two separate occasions revealed that the posted staffing information was outdated and incomplete, lacking essential details such as the facility census and the total number and hours for RNs, LPNs, and CNAs. Interviews with facility staff, including the Receptionist, Staffing Coordinator, Director of Nursing, and Administrator, highlighted a lack of awareness and adherence to the posting requirements. The Staffing Coordinator admitted to being unaware of the need to include the facility census and total staffing numbers and hours in the postings. The Director of Nursing and Administrator acknowledged that the postings should meet regulatory standards, indicating a gap in communication and training regarding compliance with staffing information regulations.
Failure to Notify State Agency of Change in Director of Nursing
Penalty
Summary
The facility failed to provide written notice to the State Agency regarding a change in the Director of Nursing (DON) position. According to the facility's policy, the governing board is required to notify the state-licensing agency of any changes in the administrator or director of nursing services. This notification should be provided at least fourteen days prior to the change taking effect, including details such as the name and license number of the new DON, the effective date of the change, and any other necessary information. However, during a review of the Health Care Facility Reporting System (HCFRS) on December 26, 2024, it was found that the facility did not submit the required notice of the change in the DON position. Interviews conducted during the survey revealed that the new DON, who had been in the role for over a month, was unaware that the facility had not reported the change in her status. The Administrator admitted during an interview that he failed to report the change to the State Agency, acknowledging that the new DON's start date was November 4, 2024. This oversight resulted in a deficiency as the facility did not comply with the established policy and state regulations regarding the notification of changes in key administrative personnel.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 1,358 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lexington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park Avenue Health Center | 1 mi | ★★★★★ | 10 | 0 |
| Meadow Green Nursing And Rehabilitation Center | 1.5 mi | ★★★★★ | 17 | 0 |
| Pine Knoll Nursing Center | 1.6 mi | — | 47 | 1 |
| Winchester Rehabilitation And Nursing Center | 2.5 mi | ★★★★★ | 3 | 0 |
| Aberjona Rehabilitation And Nursing Center | 2.5 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.