Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lexington Court Care Center during CMS and state inspections, most recent first.
A resident with severe dementia, dependent on staff for ADLs, was subjected to inappropriate care when three CNAs physically restrained her wrists during an episode of combativeness, resulting in significant bruising. Despite care plans and training that directed staff to respect the resident's right to refuse care and to use non-physical interventions, staff proceeded with care by holding her down, contrary to facility policy and best practices for dementia care.
The facility failed to maintain a clean kitchen and ensure staff wore hair restraints, affecting all 69 residents receiving meals. The Interim Dietary Manager was observed without a hair restraint, and grease was seen running down the stove. A staff member served food with a gloved hand after touching utensils, later switching to tongs. The facility's policy requires clean and sanitary food service areas, which was not followed.
A facility failed to ensure a care plan reflected a resident's current status regarding ADLs. The resident, admitted with multiple diagnoses and requiring wheelchair assistance, confirmed needing help with ADLs. However, the care plan lacked goals and interventions for ADLs, as verified by the DON. The facility's policy mandates accurate assessments of residents' functional capacity, which was not adhered to in this instance.
A resident with severe cognitive impairment and specific food preferences was served chicken despite a documented dislike, as observed during a lunch tray line. The resident's daughter confirmed the preference, and the Regional Clinical Director had to intervene for a substitution. The Registered Diet Technician lacked access to update diet preferences, contrary to facility policy.
A resident with several medical conditions, who was supposed to be supervised while smoking, was found to have four packs of cigarettes in her room's refrigerator, contrary to the facility's smoking policy. Staff interviews revealed a lack of awareness about the resident's possession of cigarettes, which were supposed to be stored securely by staff.
Failure to Provide Dignified Dementia Care Results in Resident Harm
Penalty
Summary
A deficiency occurred when staff failed to provide appropriate and dignified dementia care to a resident with severe cognitive impairment and a diagnosis of Alzheimer's disease. The resident required one-person assistance with activities of daily living (ADLs) and had care plans in place that emphasized respecting her right to refuse care, maintaining a calm environment, and not forcing her to complete tasks. Despite these documented approaches, three CNAs attempted to provide incontinence care while the resident was combative, resulting in the staff holding her wrists and arms. This led to significant bruising on both wrists and lower forearms, as confirmed by skin assessments and X-rays ordered due to complaints of pain. The incident was precipitated by the resident's refusal of care and escalating combative behaviors, including hitting, kicking, biting, and pinching. Staff attempted multiple comfort and redirection measures, but these were ineffective. Instead of discontinuing care and re-approaching later, as outlined in the care plan and facility training, the staff proceeded with care by physically restraining the resident's wrists. There was no documentation indicating that the nurse was notified of the resident's escalating behavior or that the situation required immediate intervention for safety. The medical record and investigation did not provide evidence that care could not have been delayed or that the resident was unsafe if care was postponed. Interviews with staff and review of facility policies confirmed that staff were trained to step away and re-approach residents who refused care, and that physical restraint or force was not an acceptable practice. The facility's abuse prevention policy and dementia care training both emphasized the importance of respecting resident rights and using non-physical interventions. Despite this, the staff involved did not follow these protocols, resulting in actual harm to the resident in the form of bruising and pain.
Sanitation and Hair Restraint Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment and ensure that kitchen staff wore appropriate hair restraints, potentially affecting all 69 residents who received meals from the facility kitchen. During an observation, the Interim Dietary Manager (IDM) was seen without a hair restraint and was unaware of the regulation requiring it. Additionally, grease was observed running down the front of the stove, and the IDM acknowledged the issue but did not immediately rectify it. On a subsequent observation, a staff member was seen serving garlic bread with a gloved hand after touching other utensils and plates, acknowledging the mistake and switching to tongs. Further inspection revealed an overflowing grease tray causing grease to run down the stove, and a greasy, dusty shelf above the stove. The facility's policy mandates that food service areas remain clean and sanitary, which was not adhered to in these instances.
Care Plan Deficiency for Resident's ADL Needs
Penalty
Summary
The facility failed to ensure that a care plan accurately reflected a resident's current status, specifically regarding Activities of Daily Living (ADLs). This deficiency was identified during a review of the medical record for a resident who was admitted with diagnoses including myelofibrosis, muscle weakness, migraines, and an infection of a surgical site. The resident, who was cognitively intact, confirmed during an interview that she uses a wheelchair and requires assistance from staff to complete ADLs. However, the care plan updated on 02/28/25 did not include goals and interventions for ADLs. An interview with the Director of Nursing verified that the care plan did not address the resident's ADL needs. The facility's policy requires a comprehensive and accurate assessment of each resident's functional capacity, which was not met in this case.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of Resident #42, who was admitted with diagnoses including Alzheimer's disease, heart failure, and thyrotoxicosis. The resident was severely cognitively impaired and dependent on assistance for daily activities. The care plan for Resident #42, dated 03/03/22, indicated a nutritional risk and included interventions to honor food preferences. Despite this, the resident's diet ticket noted a dislike for chicken, yet during a lunch tray line observation on 03/26/25, the resident was served pureed chicken alfredo, contrary to their stated preference. Staff member #302 indicated that Resident #42 had previously eaten chicken and did not require a substitute. However, an interview with the resident's daughter confirmed that her mother did not like chicken and preferred a substitution. The Regional Clinical Director had to call the kitchen for an alternative. Additionally, the Registered Diet Technician, who conducts monthly tray audits, revealed she did not have access to the diet ticket system to audit or update preferences. The facility's policy, dated 01/2025, stated that preferences should be obtained from the resident or their representative, highlighting a failure in adhering to this policy.
Failure to Safely Store Smoking Materials
Penalty
Summary
The facility failed to ensure that smoking materials were stored safely, affecting one resident. The resident, who was cognitively intact and required limited assistance with activities of daily living, had several medical diagnoses including hypokalemia, peripheral vascular disease, and depression. According to the resident's smoking assessment, she was to be supervised when smoking, and all smoking materials were to be stored by staff in a locked location. However, during an observation, it was found that the resident had four packs of cigarettes stored in her room's refrigerator, contrary to the facility's smoking policy. Interviews with various staff members revealed a lack of awareness regarding the resident's possession of cigarettes in her room. The Housekeeper Supervisor and Medical Records Coordinator both confirmed that the resident's cigarettes were supposed to be stored behind the nurse's station. The resident herself admitted to purchasing cigarettes through a staff member and storing them in her refrigerator, which she forgot about until they were discovered. The facility's smoking policy clearly stated that residents should not have smoking materials on their person during non-smoking times and that all unsmoked cigarettes should be returned to staff for secure storage.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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) |
|---|---|---|---|---|
| Country Meadow Rehabilitation And Nursing Center | 3.6 mi | ★★★★★ | 0 | 0 |
| Liberty Nursing Center Of Mansfield | 5.7 mi | ★★★★★ | 0 | 0 |
| Winchester Terrace | 6 mi | ★★★★★ | 3 | 0 |
| Jag Healthcare Mansfield | 6.7 mi | ★★★★★ | 0 | 0 |
| Crystal Care Center Of Mansfie | 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 June 2026) and official state health department websites.