Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lexington Health Care Center during CMS and state inspections, most recent first.
A resident with ESRD and dialysis refusal was subjected to a guardianship filing by facility staff without notifying her or her family and without a formal competency assessment. The resident was her own RP, the MDS coded her as cognitively intact, and the Medical Director noted she had not been declared incompetent. The SW filed the petition after being directed by the Administrator, while the resident stated she did not want the facility controlling her decisions and her daughter said she would have wanted to serve as guardian if needed.
Failure to Honor Resident’s Right to Refuse Hemodialysis: A resident with ESRD and moderate cognitive impairment repeatedly refused HD, but staff escalated the refusals into an involuntary commitment and law enforcement transport. EMS found the resident alert, oriented, and not an active threat, while the DON completed IVC paperwork stating the resident was dangerous to self. The resident reported being handcuffed and taken in a police car, and later said she felt she no longer had the right to refuse HD because she feared police would be called again.
Kitchen staff failed to properly label and date food items, reseal dry goods left open to air, and keep cooking equipment and the food prep area clean. Surveyors found undated prepared tomatoes and onions in a reach-in cooler, open or undated cereal and gelatin in dry storage, and grime, grease, and food particles on the gas range, oven doors, and tile grout. The DM said she was new and unsure of the deep cleaning schedule, and the Administrator said he expected all stored food to be correctly stored and labeled and the kitchen to be free of grease build-up.
A resident with moderate cognitive impairment had a wall-mounted continuous radar-monitoring device positioned above the bed, but the RP was not aware of what it was, did not recall receiving education, and did not recall signing consent. The monitoring company stated the device continuously collected data on vital signs and activity, while the DON, Admissions Director, and Administrator later confirmed the consent form was missing from the admission paperwork.
PASRR Screening Not Verified Before Admission: A resident with PTSD and adjustment disorder was admitted after an ED visit for suicidal ideations and aggressive behavior, but the facility did not ensure a current PASRR Level I was completed before admission. Staff stated the hospital usually completed the screen, yet they did not verify that it was recent or included the resident’s active mental health diagnoses.
A resident with poor dentition, dysphagia, and severe protein-calorie malnutrition remained on a pureed diet while a dental consult for dentures was ordered but not completed. The resident said she could eat better if she had teeth and reported telling staff she wanted a dental appt, but the request and order were not effectively communicated to the nurse, UM, or discharge planner, and the resident was not seen when the dentist visited the facility.
A resident returned from the smoking area with an odor of marijuana, which was reported by staff and confirmed by a positive drug screen for THC. The resident admitted to using a THC vape obtained from another resident. Despite facility policy requiring law enforcement notification in such cases, the DON and Administrator did not report the incident, citing lack of physical evidence.
A resident identified as a smoker was not assessed for smoking safety upon admission and was not supervised while smoking, despite the care plan indicating supervision was required. The resident kept smoking materials independently, and staff were unaware of the need for supervision or the resident's status, resulting in a failure to follow the facility's smoking policy.
A nurse administered 1 mL (20 mg) of morphine instead of the prescribed 0.25 mL (5 mg) to a resident with advanced cancer and multiple comorbidities, due to unclear physician orders that did not specify the correct volume. The error was identified after administration, and the resident was closely monitored and treated as needed. The incident was attributed to the lack of clarity in the medication order, requiring the nurse to calculate the dose based on concentration, leading to a failure in accurate medication administration.
A resident with metastatic lung cancer received two doses of Narcan and one dose of Lasix following a Nurse Practitioner's verbal orders, but the orders were not entered into the electronic medical record and the medication administrations were not documented on the MAR. Multiple nurses were involved in administering the medications, but confusion over responsibility and issues with the electronic system led to incomplete records.
A nurse aide solicited housing from a cognitively impaired resident, who considered allowing the aide to house-sit his home. The aide attempted to access the resident's home by seeking the key from a neighbor, who refused and alerted the resident's family. The resident, who was vulnerable due to depression, cognitive impairment, and medication use, initially agreed but later changed his mind. The facility failed to recognize and substantiate this as exploitation, and no plan of correction was completed.
A resident was allegedly exploited by a nursing assistant who attempted to gain access to the resident's personal home. Although the incident was reported to law enforcement and investigated internally, the facility failed to notify Adult Protective Services (APS) as required by policy. Staff interviews revealed confusion over reporting responsibilities, and documentation confirmed that APS was not informed of the allegation.
Multiple deficiencies were identified in the management of oxygen therapy, including a resident receiving oxygen at a higher rate than ordered, unclean oxygen concentrator filters, missing oxygen signage for three residents, failure to change oxygen tubing as ordered for two residents, and a resident receiving continuous oxygen without a physician's order or care plan intervention. Staff interviews revealed lack of awareness of facility policies and missed responsibilities in respiratory care.
Residents repeatedly reported dissatisfaction with being served the same food items, such as potatoes and green beans, multiple times a week. Despite these grievances being documented and communicated to the Dietary Manager and Administrator, no immediate changes were made to the menu, and the issue persisted for several months.
A resident with hypertension and cognitive impairment had a DNR form that was signed by an NP but lacked a date, resulting in an incomplete document. Staff interviews revealed that the admissions nurse is responsible for preparing the DNR form, which should then be signed and dated by the NP and checked during the 24-hour chart review. The missing date was identified during a review, and it was noted that the NP was new to the process.
A nurse failed to ensure a resident with moderate cognitive impairment swallowed prescribed medications, leaving a cup with nine pills on the overbed table and documenting administration without observation. The nurse left the medications unattended due to an urgent need to use the bathroom, contrary to facility policy requiring staff to watch residents take their medications.
A resident receiving enteral feedings via gastrostomy tube had a plastic syringe stored with the plunger engaged and liquid residue remaining inside, rather than being separated, rinsed, and allowed to air dry. Nursing staff were unaware of the correct procedure for cleaning and storing the syringe, and this improper practice was observed and confirmed through staff interviews.
Two residents who were assessed as safe and cognitively intact smokers were not allowed to smoke independently according to their preference, but were instead required to follow a strict, staff-supervised smoking schedule. Both residents expressed frustration and anxiety over these restrictions, and staff confirmed their repeated requests to smoke outside of scheduled times. Facility leadership stated the policy was implemented for safety, but could not explain why independently safe smokers were not permitted to smoke freely.
A resident with atrial fibrillation on warfarin therapy did not receive a scheduled INR lab as ordered, and the NP was not notified of the missed test. Documentation confirmed the INR was not checked, and interviews with nursing staff and leadership revealed a lack of awareness and communication regarding the missed lab, resulting in a deficiency related to failure to notify the provider of significant changes or omissions in care.
A resident with severe cognitive impairment and a history of wandering and aggressive behaviors was not provided with consistent supervision, particularly during overnight hours when a 1:1 sitter was not assigned. This lapse allowed the resident to enter another resident's room, take personal belongings, and make physical contact, resulting in minor injury. Staff interviews confirmed that supervision was not maintained at all times, leading to the incident.
A resident with atrial fibrillation on warfarin therapy did not receive an ordered INR test after the medication was held due to elevated levels. Although the warfarin was not administered as directed, there was no documentation or lab result for the required INR test, and staff interviews confirmed the test was missed.
A facility failed to update a care plan for a resident who no longer had an indwelling urinary catheter. Despite the catheter's removal and a subsequent MDS assessment indicating frequent urinary incontinence, the care plan still included the catheter. The MDS nurse confirmed the oversight, and the Administrator expected the care plan to accurately reflect the resident's condition.
A facility failed to maintain accurate medical records for a resident's medication management. The resident had orders for Atorvastatin, Insulin Lispro, and water flushes, which were not documented as administered or refused on the MAR. A nurse confirmed she provided the medications but forgot to sign off. The administrator expects complete and accurate records.
A resident in a long-term care facility was affected by the misappropriation of Hydrocodone tablets, which were not administered as needed and went missing from the medication cart. Despite receiving scheduled Oxycodone, the Hydrocodone was last accounted for during a narcotic count but was missing during the next shift change. Four nurses had access to the medication cart, but none admitted to taking the medication, and all tested negative for opiates. The facility's investigation could not determine the responsible party, and the local police and DEA were notified.
A resident, who required a two-person assist for bed mobility, fell from the bed while receiving care from a Hospice Aide who did not follow the care plan. The aide attempted to provide care alone, resulting in the resident falling and sustaining a skin tear. The incident revealed a failure in communication and adherence to care protocols.
Guardianship Filed Without Resident or Family Communication
Penalty
Summary
The facility failed to treat a resident in a dignified manner when staff filed for legal guardianship without communicating with the resident or her family and without a formal evaluation or assessment showing that she was incompetent. The resident was admitted with diagnoses including end stage renal disease, hypertension, anoxic brain damage, dependence on renal dialysis, cognitive communication deficit, and muscle weakness. Her face sheet identified her as her own responsible party, and her significant change MDS coded her as cognitively intact with no behavior or rejection of care. The record showed the resident had a history of refusing dialysis and medications, and the Medical Director documented that her cognitive impairment made comprehension of her decisions doubtful, but she had not been declared incompetent and family were not willing to force the issue. Care plans addressed refusal of medications and dialysis and noted she was expected to return to the community. A later physician note stated the resident believed she did not have chronic kidney disease, had been educated, and wanted to speak with her ex-husband before making decisions. The Social Worker filed a court petition for guardianship after being directed by the Administrator, stating the resident's family could not be contacted. However, the Social Worker, Administrator, and DON all acknowledged that no formal assessment or evaluation had been completed to deem the resident incompetent. The resident stated she had not been notified of the guardianship filing, did not understand why it was being pursued, and said she did not want the facility to oversee her decision-making. Her daughter also stated she had not been notified and would have wanted to serve as guardian if needed.
Failure to Honor Resident’s Right to Refuse Hemodialysis
Penalty
Summary
The facility failed to honor a resident’s right to refuse treatment when the resident declined hemodialysis on multiple occasions and staff responded by initiating an involuntary commitment. The resident was admitted with end stage renal disease requiring hemodialysis, a history of anoxic brain injury, and was documented as moderately cognitively impaired on a comprehensive MDS assessment. Her care plan identified the need for community hemodialysis three times weekly, and later added a focus area for refusal of medications and hemodialysis due to denial of health conditions. Records and interviews showed the resident refused hemodialysis five times before the event in question. On the day staff escalated the matter, the NP documented that the resident continued to be noncompliant with hemodialysis, acknowledged understanding of the need for treatment, and stated she might not return for further dialysis after one more session. EMS later found the resident alert and oriented, lying in bed, and refusing transport. EMS documented that the resident denied complaints, denied wanting transport, and showed no indication of being an active threat to herself or others at that time. EMS also noted the facility could not produce court-mandated paperwork showing guardianship or equal authority. Despite this, the DON completed an affidavit and petition for involuntary commitment stating the resident had a mental illness and was dangerous to self or others, and the facility arranged for law enforcement transport. The resident reported that an officer walked her out of the facility, handcuffed her hands in front of her body, and placed her in the back of the police car. She stated she did not understand what was happening, had no prior law enforcement experience, and felt upset and aggravated but cooperative. The officer reported the resident was calm, cooperative, and not a danger to herself or others, and the hospital physician later documented that she had capacity to make her own treatment decisions and was safe for discharge. The resident stated afterward that she felt she no longer had the right to refuse hemodialysis because she feared law enforcement would be contacted again if she did so.
Kitchen Food Storage and Sanitation Deficiencies
Penalty
Summary
Food items were not properly labeled and dated in the kitchen storage areas. During an initial tour of the main kitchen, surveyors found undated prepared containers of sliced fresh tomatoes and sliced fresh onions in reach-in cooler #2. In the dry storage area, a 35 oz. bag of crisped rice cereal, a 35 oz. bag of corn flakes cereal, and a 24 oz. open-to-air bag of strawberry gelatin in the original container were found left open to air and/or without a date. Surveyors also observed unsanitary conditions in the food preparation area. The gas cooking range had visible grime and grease build-up on four burners, the glass oven doors had visible grease build-up and food particles, and grease build-up and food crumbs were present in the tile grout in front of the cooking and food preparation areas. The Dietary Manager stated she had recently started in the role and was unsure of the deep cleaning schedule, and the Administrator stated he expected the kitchen to be free of grease build-up and that all food stored in the kitchen would be correctly stored and labeled.
Missing consent and education for radar-monitoring device
Penalty
Summary
The facility failed to obtain written consent and failed to educate the resident or the Responsible Party for the use of a continuous radar-monitoring system mounted on the wall above Resident #35’s bed. Resident #35 was admitted to the facility on [DATE], and the admission MDS dated [DATE] indicated she was moderately cognitively impaired. During an observation on 6/22/26 at 12:00 PM, a small white device with no lens or light was seen mounted above her bed and pointed directly at the bed. A review of the monitoring company’s website showed the device continuously monitored vital signs and activity through clothing and bedding using radar-based sensors, with data sent to a centralized dashboard for facility staff access. The monitoring company representative stated the device continuously collected data and was never physically turned off, although the data would not be monitored until consent was signed. He also stated the system relied on nursing documentation of discharge or room change to know when a resident moved, and that the device monitored metrics such as heart rate and respirations. The resident’s RP stated he was not aware of what the device was, thought it might be a camera, and did not recall receiving education or signing a consent form for its use during admission paperwork. He said he could not decide whether he was okay with the device because he did not know what it monitored. When the signed consent forms were reviewed on 6/26/26, none were present for Resident #35. The DON, Admissions Director, and Administrator later acknowledged that the consent form was missing and that the Admissions Director had missed the consent form and accompanying education when completing the admission paperwork with the RP.
PASRR Screening Not Verified Before Admission
Penalty
Summary
The facility failed to ensure a PASRR Level I screening was completed prior to admission for a resident with diagnoses including PTSD and adjustment disorder with mixed disturbance of emotions/conduct. The resident had been transferred from the ED after law enforcement brought him in for evaluation of involuntary commitment due to suicidal ideations and aggressive behaviors. In the ED, he reported that he had made suicidal statements during an argument with a family member related to a stressful living situation, denied wanting to hurt himself or others, and was found not to meet criteria for involuntary commitment. He was then hospitalized for placement assistance and later admitted to the facility with no acute psychiatric concerns noted during the hospitalization. Record review showed a PASRR Level I had been completed in 2022, but staff could not confirm that a recent Level I PASRR had been completed during the resident’s most recent hospitalization before admission. The admission MDS documented that the resident was cognitively intact, had no behaviors or rejections of care, was not receiving psychotropic medications, and was not currently considered by the state Level II PASRR authority to have a serious mental illness or intellectual disability. Interviews with the Discharge Planner, Former Social Worker, and Administrator indicated the facility expected the hospital case managers to complete the Level I PASRR, while the facility was responsible for reviewing it to ensure it was current and included the resident’s active mental health diagnoses; however, the Former Social Worker stated she did not complete or review Level I PASRRs to verify those details for newly admitted residents.
Failure to Arrange Dental Consult for Resident With Poor Dentition
Penalty
Summary
The facility failed to provide the necessary assistance to obtain dental services for one resident who had poor dentition, difficulty chewing, and severe protein-calorie malnutrition. The resident was admitted with dysphagia oral phase and protein-calorie malnutrition, was on a mechanically altered/pureed diet, and was not initially coded for swallowing or dental/oral concerns on the admission MDS. During a routine medical visit, the resident reported that she was receiving a pureed diet, did not like most of the meals, and stated she could eat better if her teeth were better, so a dental consult was ordered for dentures. The physician order for the dental consult was entered for poor dentition and dentures, but the consult was not completed before the order end date. The resident continued on a pureed diet with nutritional supplements three times daily, though she was refusing the supplements. The NP noted the dental consult was pending and that the resident remained nutritionally monitored, while the resident was observed with several missing teeth and stated she wanted to be evaluated for dentures because she did not like the pureed food and believed she would not need the diet if she had teeth and could chew. Interviews showed the resident had told multiple staff members she wanted a dental appointment, but the request was not effectively communicated or acted upon. The NA stated she notified the nurse of the resident’s request, but the nurse did not recall being told and did not recall seeing the dental consult order. The nurse stated she would have notified the Unit Manager or Discharge Planner if aware of the request or order, but the Unit Manager and Discharge Planner were unaware of the consult. The facility’s dental provider visited the facility during the period in question, but the resident was not seen during that visit.
Failure to Report Suspected Drug Use to Law Enforcement
Penalty
Summary
The facility failed to report a reasonable suspicion of a crime to law enforcement after a resident was identified with an odor of marijuana upon returning from the smoking area. Staff immediately reported the odor to the assigned nurse, who then conducted a drug screen with the resident's consent. The drug screen tested positive for cannabinoids (THC), and the resident later admitted to having smoked a THC vape obtained from another resident. A search of the resident's room was conducted, but no illegal substances were found. Despite the facility's policy requiring law enforcement to be contacted when items posing a health and safety risk are found or suspected, the Director of Nursing and the Administrator decided not to notify law enforcement. Their rationale was based on the absence of physical evidence after the room search and the belief that law enforcement would not be able to take further action. The failure to report the incident to law enforcement constituted a deficiency in following the facility's own policy and regulatory requirements.
Failure to Assess and Supervise Smoking Resident per Policy
Penalty
Summary
The facility failed to complete a smoking assessment upon admission for a resident who was identified as a smoker and did not provide supervision or retain smoking materials in accordance with its smoking policy. The resident's care plan, initiated at admission, indicated a preference for smoking and required supervision, but there was no evidence of a completed smoking assessment until several months later. Staff interviews revealed confusion and lack of awareness regarding the resident's smoking status and supervision needs, with some staff believing the resident was independent and others unaware of the care plan requirements. The resident reported smoking independently since admission and keeping smoking materials in his possession, contrary to the facility's policy for supervised smokers. Observations confirmed that the resident was never supervised while smoking and had unrestricted access to cigarettes and a lighter. Staff members, including nurse aides and nurses, stated they were not informed or educated about the resident's need for supervision and did not recall the resident being listed as a supervised smoker. Unit management and the administrator were also unaware of the lack of an initial smoking assessment and the discrepancy between the care plan and actual practice. Communication breakdowns were evident, as staff relied on posted lists and verbal updates, which did not accurately reflect the resident's assessed needs. The facility's failure to assess, supervise, and control access to smoking materials for a resident requiring supervision constituted a deficiency in accident prevention and adherence to policy.
Incorrect Morphine Dose Administered Due to Order Clarity and Measurement Error
Penalty
Summary
A nurse failed to accurately measure and administer a liquid narcotic medication, resulting in a resident receiving a significantly higher dose of morphine than prescribed. The physician's order specified morphine sulfate concentrate at a strength of 20 mg/mL, with instructions to give 5 mg by mouth every two hours as needed. However, the order did not specify the corresponding milliliter amount for the 5 mg dose, requiring the nurse to calculate the correct volume. On the night in question, the nurse signed out and administered 1 mL (20 mg) of morphine instead of the prescribed 0.25 mL (5 mg), as documented on the controlled substance receipt sheet and the Medication Administration Record (MAR). The error was identified by the nurse shortly after administration, and she reported the incident to the provider. The resident, who had a complex medical history including metastatic lung cancer, heart failure, COPD, anxiety disorder, and other conditions, was being managed with comfort measures and was not morphine-naive. The nurse and nurse aide closely monitored the resident's vital signs and oxygen saturation following the administration of the incorrect dose. The resident initially remained alert and stable, but later became less responsive, prompting further assessment and intervention by the nurse practitioner, including administration of Narcan to reverse the effects of the morphine. Interviews with facility staff, including the DON, nurse manager, nurse practitioner, pharmacist, and medical director, confirmed that the error was due to the lack of clarity in the original physician order, which did not specify the volume to be administered. The error was not attributed to a lack of knowledge or intent, but rather to the need for calculation based on the medication concentration. The incident was recognized as a failure to follow professional standards of medication administration, specifically in ensuring accurate measurement and documentation of narcotic medications.
Failure to Document Medication Orders and Administration in Resident Record
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's medical record was complete regarding medication orders and documentation of medication administration. A resident with metastatic lung cancer was admitted and, during an episode of non-responsiveness, a Nurse Practitioner (NP) gave verbal orders for two doses of Narcan and one dose of Lasix. These medications were administered by nursing staff, as confirmed by sign-out records from the emergency medication supply. However, the orders were never entered into the resident's electronic medical record, and the administration of these medications was not documented on the Medication Administration Record (MAR). Multiple nurses were present when the NP gave the orders, but the NP did not specify which nurse was responsible for entering the orders. One nurse attempted to enter the order for Narcan but was unable to find the correct form in the electronic system, resulting in the order not being entered and the administration not being documented. Interviews with staff confirmed that the medications were administered per the NP's verbal orders, but no documentation was made in the resident's record or MAR, as required by facility policy and professional standards.
Failure to Protect Resident from Exploitation by Staff
Penalty
Summary
A nurse aide (NA) at the facility engaged in conduct that failed to protect a resident's right to be free from exploitation. The NA discussed her personal housing difficulties with a resident who was moderately cognitively impaired, suffering from depression, anxiety, and a cognitive communication disorder. The NA asked the resident if she could live in his personal home while he was at the facility, and the resident, described as goodhearted and trusting, considered allowing the NA and her friend to house-sit. The resident provided information about where the house key was located, and the NA attempted to access the home by searching for the key and then requesting it from the resident's neighbor. The neighbor refused to provide the key and notified the resident's family member, who was the financial proxy and health power of attorney. The family member and neighbor reported the incident to facility administration. Interviews with the resident, the NA, the neighbor, and the family member revealed that the resident initially agreed to allow the NA to stay at his home but changed his mind after learning more about the NA's personal situation. The NA claimed her intent was to assess the home for providing private care after the resident's discharge, but she admitted to going to the house and seeking the key from the neighbor. The neighbor and family member both stated that the NA expressed a desire to stay in the resident's home, and the family member emphasized the resident's vulnerability due to his cognitive and emotional state, as well as his use of pain medications. The NA was suspended and subsequently terminated for attendance issues, but the facility's initial investigation did not substantiate the allegation of exploitation, focusing instead on the lack of harm and the fact that the NA did not gain access to the home or property. Despite the lack of physical harm or property loss, the facility failed to recognize and substantiate the exploitation that occurred when the NA attempted to benefit from her relationship with a vulnerable resident by seeking access to his personal home. The former administrator later acknowledged that the situation should have been substantiated as exploitation, given the NA's actions and the resident's inability to fully understand the ramifications. The facility did not complete a plan of correction for misappropriation of property or exploitation related to this incident.
Failure to Report Alleged Exploitation to APS
Penalty
Summary
The facility failed to report an allegation of misappropriation of property and exploitation to Adult Protective Services (APS) as required by its own policy. The policy stated that the Administrator must immediately notify APS of any incident involving abuse, mistreatment, neglect, or misappropriation of personal property. In this case, a resident was allegedly exploited by a nursing assistant (NA), who attempted to gain access to the resident's personal home by convincing the resident to allow her to stay there and by seeking a key from the resident's neighbor. The neighbor and a family member, who was the resident's financial proxy and health power of attorney, reported that the resident was easily manipulated and that the NA attempted to exploit the resident to become a squatter in the resident's home. The facility became aware of the incident and suspended the NA pending investigation, and notified local law enforcement, but there was no documentation that APS was notified at any point. Interviews with facility staff revealed a lack of communication and clarity regarding the responsibility for reporting such incidents to APS. The former Administrator could not recall if APS was notified and stated that the Social Worker was usually responsible for such notifications, but the Social Worker reported she was not informed of the incident and therefore did not notify APS. The investigation report and other documentation confirmed that APS was not notified of the allegation, and facility leadership acknowledged that no plan of correction was completed for this reporting failure.
Deficiencies in Oxygen Therapy Management and Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to several residents, as evidenced by multiple deficiencies in oxygen therapy management. One resident with respiratory failure, pneumonia, and stroke was observed receiving oxygen at a rate higher than the physician's order, with the oxygen concentrator's air intake filter covered in dust. Staff interviews revealed a lack of knowledge regarding the cleaning schedule and manufacturer's instructions for the concentrator, and the resident's oxygen order was not followed until after the discrepancy was identified. The facility's policy required cleaning according to manufacturer guidelines, but this was not consistently implemented. Three residents receiving continuous oxygen therapy did not have required oxygen signage posted near their rooms, despite being observed with oxygen concentrators in use. Staff, including the unit manager and DON, were unaware that signage was missing and did not know it was required by facility policy. Additionally, two residents had not had their oxygen tubing changed as ordered, with tubing observed to be dirty and dated two weeks prior. Staff interviews indicated that tubing changes were missed due to lack of supplies and competing priorities during shifts, and management was not aware of the missed changes. Another resident was found to be on continuous oxygen without a physician's order or care plan intervention for oxygen use. The resident had been on oxygen for at least a week, and both the unit manager and nurse practitioner assumed an order was in place or that it had been missed. The DON confirmed that nursing staff should have ensured an order was entered when the resident began oxygen therapy, but this was not done. These findings demonstrate failures in following physician orders, maintaining equipment, ensuring proper documentation, and adhering to facility policies for respiratory care.
Failure to Address Resident Grievances Regarding Repetitive Menu Items
Penalty
Summary
The facility failed to resolve grievances reported by residents during Resident Council meetings over a period of four out of six months. Residents repeatedly complained that they were being served the same food items, specifically potatoes and green beans, multiple times a week for both lunch and dinner. These concerns were documented in the Resident Council Minutes and were consistently brought to the attention of facility staff, including the Dietary Manager and the Administrator. Despite these ongoing complaints, the menu remained unchanged, with the Dietary Manager indicating that the menu was provided by the corporate office and could not be altered. Residents expressed ongoing dissatisfaction, stating that their concerns about repetitive meals were not addressed and the issue persisted over several months. Staff interviews confirmed that the complaints were a consistent problem and that the Administrator was aware of the grievances. However, the facility did not implement any immediate changes to the menu, and the same food items continued to be served as per the existing schedule.
Incomplete DNR Form Due to Missing Date
Penalty
Summary
The facility failed to fully complete a Do Not Resuscitate (DNR) form for a resident with diagnoses including hypertension and cognitive impairment. Upon review, the resident's DNR form was found to be signed by the Nurse Practitioner (NP) but was missing the required date. The electronic medical record did contain a physician's order for DNR with a date, but the paper DNR form itself was incomplete. Interviews with staff revealed that the process for completing DNR forms involves the admissions nurse filling out the form, which is then to be signed and dated by the NP before being scanned into the electronic record and stored in a binder at the nurse's station. Both the Unit Manager and DON confirmed that the DNR form should be dated and checked during the 24-hour chart review after admission. The NP stated that forms are typically dated before she signs them, but in this instance, the date was missing. The Administrator acknowledged that the NP was responsible for both signing and dating the form and noted that the NP was new to the process.
Medications Left Unattended; Nurse Failed to Ensure Ingestion
Penalty
Summary
A deficiency occurred when a nurse failed to ensure a resident swallowed their prescribed medications during medication administration. The resident, who was moderately cognitively impaired and had diagnoses including diabetes and congestive heart failure, was observed with a medication cup containing nine pills left on her overbed table. The resident was unable to identify the medications or the reason they were present. The nurse responsible for administering the medications reported that she had an urgent need to use the bathroom and left the medications with the resident, without confirming ingestion. The nurse had documented the medications as administered in the medication administration record, despite not witnessing the resident take them. Interviews with facility leadership confirmed that the nurse did not follow expected procedures, which require staff to observe residents swallowing their medications and prohibit leaving medications at the bedside. The nurse acknowledged that the resident may have spit out the pills after initially putting them in her mouth. Both the DON and the Administrator stated that the nurse's actions did not align with facility policy or professional standards for medication administration.
Improper Storage and Handling of Enteral Feeding Syringe
Penalty
Summary
A deficiency was identified regarding the storage and handling of an enteral feeding syringe for a resident with a gastrostomy tube. The resident, who had a history of stroke and difficulty swallowing, was receiving enteral feedings and medications through the tube as ordered by her physician. Observations revealed that the plastic syringe used for administering feedings and medications was stored with the plunger engaged in the barrel and contained a cream-colored liquid residue. The syringe was kept in a plastic bag hanging from the feeding pump pole, and this condition persisted for several hours after use. Interviews with nursing staff indicated a lack of awareness regarding the proper procedure for cleaning and storing the syringe. Both the nurse in training and the supervising nurse were unaware that the plunger should be separated from the barrel, and the syringe should be rinsed and allowed to air dry before storage. The nurse practitioner confirmed that the enteral feeding product contained sugar, which could promote bacterial growth if left in the syringe. The improper storage and cleaning practices were directly observed and confirmed through staff interviews.
Failure to Honor Resident Choice for Independent Smoking
Penalty
Summary
The facility failed to honor the rights of residents who were assessed as safe smokers to smoke independently according to their personal preference. Despite both residents being evaluated as cognitively intact and safe to smoke unsupervised, the facility required them to adhere to a strict smoking schedule and only allowed smoking at designated times under staff supervision. The facility's policy and smoking assessment documentation indicated that residents deemed safe could smoke independently, but in practice, all residents were restricted to the same supervised schedule. This restriction was not based on individual assessments but rather a facility-wide policy change. Two residents expressed frustration and anxiety due to their inability to smoke when they wished, with one resident reporting increased anxiety and another expressing upset and frustration at having to wait for staff and scheduled times. Staff interviews confirmed that these residents frequently requested to smoke outside of the scheduled times and became upset or anxious when unable to do so. Facility leadership acknowledged the policy was implemented for safety reasons after previous incidents of residents smoking in unsafe areas, but could not provide a reason for restricting independently assessed safe smokers to the supervised schedule.
Failure to Notify NP of Missed INR Lab for Resident on Anticoagulant Therapy
Penalty
Summary
The facility failed to notify the Nurse Practitioner (NP) when a resident's ordered International Normalized Ratio (INR) test was not completed as scheduled. The resident, who had a history of atrial fibrillation and was prescribed warfarin, had an elevated INR of 4.0, prompting the NP to order the medication to be held and the INR to be rechecked on a specific date. Documentation showed that the warfarin was not administered during the specified period, but there was no record of the INR test being completed or its results for the ordered date. Nurse #1, who was assigned to the resident on the day the INR was to be checked, could not recall performing the test and confirmed that if the result was not documented, the test was not done. Interviews with the NP, DON, and Administrator confirmed that the INR was not checked as ordered and that the NP was not notified of the missed lab. The NP stated that she expected to be informed if the lab was not completed, especially given the resident's fluctuating INR levels and the need for close monitoring. The DON and Administrator also indicated that they were unaware the lab had been missed and agreed that the NP should have been notified. The lack of notification and failure to follow through with the ordered lab test constituted the deficiency.
Failure to Provide Adequate Supervision for Resident with Wandering Behaviors
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision to prevent a resident with known wandering and behavioral issues from entering another resident's room and attempting to take personal belongings during the night. The resident in question had a history of severe cognitive impairment, agitation, hallucinations, delusions, and physical behaviors that impacted her care and interactions. Despite documented behaviors such as wandering, aggression, and poor safety awareness, supervision was not consistently maintained, particularly during the overnight shift when a 1:1 sitter was not assigned. The resident's care plan and medical records indicated ongoing behavioral challenges, including restlessness, resistance to redirection, and attempts to enter other residents' rooms. Staff notes and psychiatric assessments repeatedly documented the resident's difficulty with redirection and her tendency to wander and interact inappropriately with others. On the night of the incident, staff responsible for supervising the resident were attending to other duties, leaving the resident unsupervised, which allowed her to enter another resident's room and take his cell phone and glasses. The incident was only discovered when the other resident called out for help. Interviews with staff confirmed that supervision was not maintained at all times, especially during the night shift, and that the resident was not assigned a dedicated 1:1 sitter during those hours. The lack of continuous supervision, despite the resident's documented behaviors and risks, directly led to the incident where she was able to access another resident's belongings and make physical contact, resulting in minor skin indentations. The facility's failure to ensure adequate supervision for a resident with known high-risk behaviors constituted the deficiency.
Failure to Complete Ordered INR Test for Resident on Anticoagulant Therapy
Penalty
Summary
A deficiency occurred when the facility failed to complete an International Normalized Ratio (INR) test as ordered by the physician for a resident receiving anticoagulant therapy. The resident, who had a history of atrial fibrillation and was on warfarin, had fluctuating INR levels that required close monitoring. Physician orders specified that the resident's warfarin should be held and the INR rechecked on a specific date following an elevated INR result. Documentation review revealed that the warfarin was appropriately held, but there was no record of the required INR test being completed on the ordered date. Nursing staff could not confirm that the test was performed, and there was no lab result or documentation to indicate it was done. Interviews with facility staff, including the nurse assigned to the resident, the Nurse Practitioner, the DON, and the Administrator, confirmed that the INR test was missed and not documented as completed. The care plan for the resident included completing labs as ordered and reporting abnormal results, but the lack of follow-through on the physician's order for INR testing constituted a failure to ensure the resident's drug regimen was free from unnecessary drugs and was properly monitored.
Failure to Update Care Plan for Urinary Catheter Removal
Penalty
Summary
The facility failed to revise the care plan for a resident who no longer had an indwelling urinary catheter. The resident was admitted with a neuromuscular disorder of the bladder and initially had a care plan for an indwelling urinary catheter due to neurogenic bladder. A nursing progress note indicated that the catheter was removed, and a subsequent Minimum Data Set (MDS) assessment showed the resident had frequent urinary incontinence and was not coded as having an indwelling urinary catheter. However, the active care plan, last reviewed on December 3, 2024, still included the catheter. During an interview, the MDS nurse confirmed the oversight, acknowledging that the care plan should have been updated to reflect the resident's current status. The Administrator expressed that the care plan should accurately represent the resident's condition.
Failure to Maintain Accurate Medication Records
Penalty
Summary
The facility failed to maintain accurate medical records for a resident in the area of medication management. The deficiency involved a resident who was admitted to the facility and had physician orders for Atorvastatin, Insulin Lispro, and water flushes via G-tube. On January 18, 2025, the Medication Administration Record (MAR) did not indicate that these medications and treatments were provided or refused at 6:00 PM. Nurse #1, who was responsible for the resident's care during that time, confirmed in a phone interview that she administered the medications and water flush but forgot to document it in the MAR. The facility administrator stated that medical records are expected to be complete and accurate.
Misappropriation of Controlled Medications in LTC Facility
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of controlled medications. The incident involved a resident who was admitted with a diagnosis of arthritis and had orders for Oxycodone and Hydrocodone for pain management. Despite the resident receiving scheduled Oxycodone, the Hydrocodone tablets, which were prescribed as needed, were not administered and were found to be missing from the medication cart. An investigation revealed that 26 Hydrocodone tablets were dispensed from the pharmacy but were never documented as administered. The tablets were last accounted for during a narcotic count between two nurses, but were missing during the next shift change. Four nurses had access to the medication cart, but none admitted to taking the medication, and all tested negative for opiates. The facility's investigation could not determine which nurse was responsible for the missing medication. The facility's policy on abuse, neglect, and exploitation includes the protection of resident property, and the misappropriation of the Hydrocodone tablets violated this policy. The investigation involved reviewing the actions of the nurses who had access to the medication cart, but the missing medication was never found. The local police and Drug Enforcement Administration were notified, and the facility submitted a report of loss or theft of controlled substances.
Failure to Provide Adequate Supervision and Assistance
Penalty
Summary
The facility failed to provide adequate supervision and care for a resident, leading to an accident. Resident #5, who was moderately cognitively impaired and required extensive assistance from two staff members for bed mobility, was left in the care of a Hospice Aide who did not follow the care plan. The care plan specified that Resident #5 needed a two-person assist for bed mobility and transfers, but the Hospice Aide attempted to provide care alone, resulting in the resident falling from the bed. During the incident, the Hospice Aide was giving Resident #5 a bed bath without the assistance of another staff member, contrary to the care plan requirements. The resident rolled off the bed and fell approximately three and a half feet, landing on her right side. This fall resulted in a skin tear on the resident's face. The Hospice Aide admitted to not using a second person for assistance, despite knowing that the resident typically required it. Interviews with staff revealed that the Hospice Aide did not check in with the facility's nursing staff to verify the care plan requirements. The Unit Manager confirmed that hospice staff had been educated on the resident's needs but was unsure why the Hospice Aide did not seek assistance. The incident highlighted a breakdown in communication and adherence to established care protocols, leading to the resident's fall.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 204 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) |
|---|---|---|---|---|
| Abbotts Creek Center | 2.5 mi | ★★★★★ | 5 | 0 |
| Pine Acres Center For Nursing And Rehabilitation | 2.9 mi | ★★★★★ | 6 | 0 |
| Davidson Health & Rehab Center | 5.1 mi | ★★★★★ | 3 | 0 |
| Piedmont Crossing | 7.7 mi | ★★★★★ | 0 | 0 |
| Pine Ridge Health And Rehabilitation Center | 9.5 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 October 2026) and official state health department websites.