Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Abbotts Creek Center during CMS and state inspections, most recent first.
A resident with COPD, who was cognitively intact and not coded for oxygen use on the MDS, was started and maintained on supplemental O2 at 2 L/min by nasal cannula without an active physician order. Nursing notes showed the resident developed shortness of breath and was assessed by the Medical Director, who ordered nebulizer treatments and a steroid but not oxygen. The resident reported being placed on oxygen when she had trouble breathing, and staff observations over several days confirmed ongoing oxygen use. A nurse believed oxygen had been reordered but could not find an order, the NP documented to continue oxygen without verifying active orders, and the DON acknowledged the prior oxygen order had been discontinued and that a new order should have been obtained before restarting O2.
Nursing staff failed to follow physician-ordered hold parameters for Metoprolol in two residents with hypertension. One resident with severe cognitive impairment received Metoprolol on multiple occasions despite heart rates below the ordered threshold, as documented on the MAR and confirmed by the involved nurses, who described the administrations as oversights. Another cognitively intact resident received Metoprolol twice when systolic BP readings were below the ordered hold parameter, with the administering nurse acknowledging the error. The Medical Director and DON both stated they expected staff to follow the ordered parameters for blood pressure medications.
Surveyors found that a controlled medication, liquid lorazepam 2 mg/ml, requiring refrigeration was stored unsecured in the door of a medication room refrigerator instead of in the permanently affixed internal lock box. A nurse reported that staff did not have a key to the internal lock box and that the refrigerator door itself was not locked, despite acknowledging that the lorazepam should have been secured inside the box. The DON and Administrator each stated they had been unaware that staff lacked access to the internal lock box and both indicated that refrigerated controlled medications were expected to be stored in the secured internal compartment.
Surveyors found that PTAC units in two occupied rooms had dark brown spots and caked substance on every vent slat while the units were running, indicating they had not been properly cleaned according to the facility’s every-two-month schedule. The Maintenance Director stated he was solely responsible for cleaning PTAC vents and filters, that the last cleaning occurred several months earlier, and that he was behind on the scheduled work. The Housekeeping Manager reported that housekeeping only wiped the exterior surfaces and did not clean vents, and the Administrator confirmed that maintenance was responsible for ensuring PTAC units were kept clean.
The facility failed to accurately post daily nurse staffing and resident census information. Over an extended review period, surveyors found that the publicly posted daily nurse staffing sheets frequently did not match the internal schedules, with incorrect numbers and types of staff (RNs, LPNs, NAs, MAs) listed for various shifts. On multiple days, staff were shown on the postings who were not scheduled, and scheduled staff were omitted or misassigned to different shifts. Additionally, on certain weekend days, the required resident census was missing from the posted staffing sheets because the staff scheduler, who did not work weekends, completed the postings after returning, and no other staff member was assigned to enter the census information in real time. Interviews confirmed that a new payroll/scheduling system was generating the postings from a data report that did not reflect the actual working schedule, and staff were unable to edit the postings to correct the inaccuracies.
A resident with multiple diagnoses, including diabetes and depression, did not have a comprehensive care plan addressing their use of insulin, anticoagulants, and antidepressants. The facility's process for developing care plans was not followed, as confirmed by the DON, leading to this deficiency.
A facility failed to arrange home health services for a resident discharged with severe cognitive impairment and multiple health conditions. The discharge plan required home health agency support for ADL assistance, medication management, PT, OT, and a social worker. However, no documentation or referrals were found, and the administrator acknowledged the oversight.
Failure to Obtain Physician Order for Supplemental Oxygen
Penalty
Summary
The deficiency involves the facility’s failure to obtain a physician’s order for supplemental oxygen before initiating and continuing its use for a resident with COPD. The resident was cognitively intact and not coded as using supplemental oxygen on the most recent MDS, and there was no active order for oxygen in the medical record. Nursing notes documented that the resident developed shortness of breath and was assessed by the Medical Director, who ordered nebulizer treatments and a steroid but did not order oxygen. Despite this, the resident was started on oxygen via nasal cannula at 2 L/min, and this treatment continued over several days without a corresponding physician’s order in the chart. Surveyor observations on multiple days confirmed the resident was receiving oxygen at 2 L/min by nasal cannula. The resident reported she had been placed on oxygen a few days earlier when she had trouble breathing. A nurse stated the resident had previously had an oxygen order that was later discontinued and believed the Medical Director had reordered oxygen, but she could not locate any such order. The Medical Director confirmed he had not ordered oxygen and stated the resident should have had an order before oxygen was initiated. The NP documented in a progress note to continue oxygen after assessing the resident while she was already on 2 L/min, but she did not review the active orders and did not realize there was no oxygen order in place. The DON acknowledged the resident’s prior oxygen order had been discontinued and that staff should have obtained a new order before restarting oxygen.
Failure to Follow Metoprolol Hold Parameters for Two Residents
Penalty
Summary
The deficiency involves nursing staff administering Metoprolol outside of ordered parameters for two residents, contrary to physician orders. Resident #2, admitted with hypertension and severe cognitive impairment, had a physician order for Metoprolol 25 mg once daily with instructions to hold the medication if the heart rate was less than 60 or if the systolic blood pressure was less than 100 or diastolic blood pressure was less than 60. Review of the December 2025 MAR showed that Metoprolol was administered on multiple dates when the resident’s heart rate was below 60: on 12/13 and 12/14 with a heart rate of 52 by one nurse, on 12/16 with a heart rate of 53 by another nurse, on 12/18 with a heart rate of 55 by a third nurse, and on 12/20 with a heart rate of 59 by the same nurse who administered on 12/16. The Medical Director confirmed there were no negative outcomes but stated he expected staff to follow the ordered parameters. The nurses involved, when interviewed, acknowledged that the medication should have been held and characterized the administrations as oversights. Resident #3, admitted with hypertension and cognitively intact per a quarterly MDS, had a physician order for Metoprolol 50 mg three times daily with instructions to hold the medication if the heart rate was less than 60 or if the systolic blood pressure was less than 100 or diastolic blood pressure was less than 60. Review of the January 2026 MAR showed that Metoprolol was administered on 1/2/26 at the 1:00 PM dose and the 9:00 PM dose when the systolic blood pressure was documented as 97, below the ordered hold parameter. The Medical Director again noted no negative outcomes but expected adherence to the parameters. One of the nurses who administered the medication on that date verified the administration outside the ordered parameter and stated it was an oversight. The DON stated she expected nursing staff to follow physician orders, including parameters for holding blood pressure medications.
Unsecured Refrigerated Controlled Medication in Medication Storage Room
Penalty
Summary
Surveyors identified a deficiency in the storage and security of a controlled medication requiring refrigeration in one of the medication storage rooms. During an observation of the 103 medication storage room refrigerator with a nurse, a 30 ml bottle of liquid lorazepam 2 mg/ml, a controlled benzodiazepine, was found stored in the refrigerator door rather than in the permanently affixed internal lock box. The nurse reported that staff did not have a key to the internal lock box and that there was no lock on the refrigerator door, and she acknowledged that the lorazepam should have been secured inside the affixed lock box. The DON later stated she had been unaware that nurses did not have a key to the internal lock box and confirmed that controlled medications, including lorazepam, were supposed to be stored in the secured internal lock box. The Administrator also reported being unaware that staff could not access the internal lock box and stated an expectation that refrigerated controlled medications be stored in the secured box inside the refrigerator. This situation resulted in a controlled drug being stored in an unsecured location within the medication room refrigerator, contrary to the facility’s stated practice that controlled medications requiring refrigeration be kept in a separately locked, permanently affixed compartment.
Failure to Maintain Clean PTAC Vents in Resident Rooms
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain a safe, clean, comfortable, and homelike environment in resident rooms. During an observation of one resident’s room on 1/4/26 at 10:00 AM, the PTAC (Packaged Terminal Air Conditioner) unit was found running while every vent slat was covered with dark brown spots. In another occupied room observed on 1/4/26 at 12:55 PM, the PTAC unit was also running and had a dark brown substance caked in the corners of every vent slat. These conditions were noted in 2 of 6 rooms reviewed on the upper 100 hall for environmental comfort and cleanliness. On 1/6/26 at 3:00 PM, during a follow-up observation of both rooms with the Maintenance Director, he stated that the Maintenance Department was responsible for cleaning the vents and filters of the PTAC units every two months and acknowledged that the last cleaning occurred in October 2025. He further explained he was the only person in the department and was behind on the scheduled December cleaning. The Housekeeping Manager reported that housekeeping staff only wiped down the top and front of the PTAC units during routine room cleaning and did not have the tools to clean the vents, indicating that vent cleaning was the responsibility of Maintenance. The Administrator confirmed that it was the Maintenance Director’s responsibility to ensure PTAC units were kept clean and that maintenance was expected to follow the every-two-month cleaning schedule.
Failure to Accurately Post Daily Nurse Staffing and Resident Census Information
Penalty
Summary
The deficiency involves the facility’s failure to post accurate daily nurse staffing information and to consistently include the resident census on the required daily staffing postings. Surveyors compared the facility’s daily posted nurse staffing sheets with the internal nursing schedules for a 30‑day period and found discrepancies on 28 of 30 days reviewed. On multiple dates, the number and type of staff (RNs, LPNs, NAs, and MAs) and the shifts worked, as shown on the public posting, did not match the actual staffing schedule. Examples included incorrect reporting of which shifts a medication aide worked, inaccurate counts of NAs on specific shifts, and misreporting of whether RNs or LPNs were present on evening and night shifts. Specific dates showed substantial mismatches between the posted sheets and the internal schedules. On some days, the postings understated staff actually scheduled (for example, fewer LPNs or NAs listed than were scheduled), while on other days the postings overstated staffing (for example, listing RNs or MAs who were not scheduled to work those shifts). There were also instances where the posted sheets showed staff working certain shifts when the schedule showed no such staff, and vice versa. These discrepancies occurred across all three shifts and involved multiple staff categories, including RNs, LPNs, NAs, and MAs, over the period from early December through early January. Surveyors also observed that the facility failed to include the resident census on the daily nurse staffing postings for certain days. During an observation in the lobby, the daily postings for two weekend dates lacked resident census numbers for all three shifts on one date and for the morning shift on the following date. Interviews with the weekend supervisor and the staff scheduler revealed that the scheduler, who did not work weekends, was responsible for all daily staffing sheets and had left the census information for those weekend days to be completed after returning to work. No staff member was assigned to complete or update the postings with the census on weekends, resulting in missing census information on the posted staffing sheets. In interviews, the scheduling manager confirmed that the numbers on the daily postings did not match the actual staffing schedules for the reviewed dates. She explained that the facility had recently implemented a new payroll/scheduling system that generated the daily postings from a data report rather than from the actual working schedule, and she did not know how to edit the system to reflect the true number of staff who worked each day. The administrator also confirmed that the daily staff postings and the staffing schedules did not match and stated that the facility had recently begun using the new system and that the scheduler could not modify the postings to correct them. The administrator further stated that she expected the resident census to be present on the daily postings and was not aware that the weekend supervisor was not completing the census information on those days.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident who was admitted with multiple diagnoses, including acute respiratory failure with hypoxia, atrial fibrillation, diabetes mellitus, and major depressive disorder. The resident was prescribed several medications, including insulin for diabetes, sertraline for depression, and apixaban for atrial fibrillation. Despite these significant medical needs, the care plan did not address the use of anticoagulants, insulin, or antidepressants, which are critical components of the resident's treatment regimen. The deficiency was identified through a review of the resident's records, observations, and staff interviews. The MDS Nurse indicated that the admitting nurse was responsible for initiating a baseline care plan, which the MDS Nurse would then expand into a comprehensive care plan. However, the traveling MDS Nurse who completed the resident's admission MDS assessment was unavailable for comment. The Director of Nursing confirmed that the baseline care plan should have included the resident's medication needs, highlighting a lapse in the facility's care planning process.
Failure to Arrange Home Health Services for Discharged Resident
Penalty
Summary
The facility failed to arrange home health services upon discharge for a resident who was admitted with diagnoses of paroxysmal atrial fibrillation, dementia, and congestive heart failure. The resident was severely cognitively impaired and required a hospital bed, home health agency (HHA) for activities of daily living (ADL) assistance, home health nursing for medication management, physical therapy (PT), occupational therapy (OT), and a social worker (SW) for community support. The discharge plan indicated that the resident was to be discharged home with family support and home health services starting on the specified date. However, upon review, it was found that there was no documentation available indicating that the social worker made a referral for home health assistance for the resident. The facility contacted the two home health providers they typically used and confirmed that no referrals had been made for this resident. The former social worker recalled completing the discharge planning but could not confirm if the referral was made. The facility's administrator acknowledged the failure to follow through with arranging home health services for the resident.
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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) |
|---|---|---|---|---|
| Lexington Health Care Center | 2.5 mi | ★★★★★ | 6 | 0 |
| Pine Acres Center For Nursing And Rehabilitation | 4.9 mi | ★★★★★ | 2 | 0 |
| Piedmont Crossing | 6.7 mi | ★★★★★ | 0 | 0 |
| Davidson Health & Rehab Center | 7.1 mi | ★★★★★ | 21 | 0 |
| Pine Ridge Health And Rehabilitation Center | 7.6 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.