Average — CMS composite of the measures below.
A standard survey is most likely before around October 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 L.m.c.- Extended Care during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and complex medical history reported both physical and sexual abuse involving a CNA and an LPN. While the initial allegation was reported, a subsequent sexual abuse allegation made during a follow-up interview was not reported to the state survey agency within the required two-hour timeframe, as facility staff considered it part of the original incident and did not submit a separate initial report.
A resident with a new diagnosis of bipolar disorder and severe cognitive impairment was not referred for a PASARR Level II evaluation after admission. Although the resident's care plan and assessments reflected the new mental illness diagnosis, the facility did not update or resubmit the PASARR Level I to the state as required.
A resident with dementia and COPD was admitted without documentation in their medical record that they were offered the pneumonia vaccine, as required by facility policy. The consent process was incomplete, and there was no record of consent or refusal for the vaccine.
An LPN used profanity in the presence of a resident with severe dementia and agitation during a blood sugar check, after the resident became combative and spilled juice on the LPN. Witnesses reported hearing the LPN use a derogatory term and other inappropriate language, violating facility policy and the resident's right to dignity and respect.
A resident with multiple health conditions, including urinary retention, was observed without a privacy bag for their catheter, compromising their dignity. Despite staff acknowledging the need for a privacy bag, it was not provided, violating the facility's policy on maintaining resident privacy.
The facility failed to ensure two residents had physician's orders for their code status, despite having significant medical conditions. The orders were only updated during a survey, revealing a lapse in following procedures. Interviews indicated confusion about the process and timeline for obtaining these orders, leading to the deficiency.
A resident was found with unauthorized medications, including Systane Hydration drops and Tums Chewy Bites, in their room without a physician's order. The facility's policy requires medications to be stored properly and only self-administered after assessment and approval. Staff confirmed that medications should not be left at the bedside without proper authorization.
The facility failed to properly store and label respiratory equipment for three residents, leading to deficiencies in care. A resident with acute respiratory failure had unlabeled oxygen tubing and an uncovered tank. Another resident's oxygen tubing was not dated, and a third resident's nebulizer mask was not stored correctly or changed as scheduled. Staff confirmed these issues, which violated the facility's policy for weekly changes and proper labeling.
The facility failed to properly label and store medications, with expired items found in three units. Observations revealed missing temperature checks for medication refrigerators, expired medications, and unlabeled substances. Nurses confirmed these issues, and the Interim DON emphasized the importance of labeling and checking expiration dates.
A CNA was observed passing meal trays with her hair touching the items and not sanitizing her hands after touching her hair, violating the facility's hand hygiene policy. She also failed to change gloves after assisting a resident in bed before feeding them. Staff interviews confirmed awareness of proper procedures, which were not followed.
A resident with moderate cognitive impairment was verbally abused by a CNA, who allegedly told her to "go home and die." The incident was reported by the resident's daughter and corroborated by the resident. Despite the facility's policy against abuse, the CNA was terminated for poor customer service rather than reported for abuse, indicating a failure in the facility's reporting procedures.
Failure to Timely Report Additional Abuse Allegation
Penalty
Summary
The facility failed to submit an initial report of a staff-to-resident abuse allegation to the state survey agency within the required two-hour timeframe for one resident. According to facility policy, any alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, but not later than two hours after the allegation is made. In this case, a resident with a history of depression, cognitive impairment, and brain cancer reported concerns of physical and sexual abuse involving a CNA and an LPN. The resident initially disclosed physical abuse and later, during a follow-up interview, made an additional allegation of sexual abuse involving the same LPN. Despite the second allegation being made during the follow-up interview, the Assistant Director of Nursing, who was the Abuse Coordinator, did not submit a separate initial report for the new allegation, considering it part of the original incident. The facility's investigation file did not include an initial report for the sexual abuse allegation, and the Administrator confirmed that both allegations were combined into one investigation. Interviews with facility leadership indicated awareness that the initial report should have been sent within two hours, but this protocol was not followed for the second allegation.
Failure to Update PASARR After New Mental Illness Diagnosis
Penalty
Summary
The facility failed to refer a resident for a Preadmission Screening and Resident Review (PASARR) Level II after the resident received a new diagnosis of a severe mental illness. The resident was originally admitted with no diagnosis of mental illness, as indicated by the initial PASARR Level I screening. However, subsequent documentation, including the resident's Face Sheet and Minimum Data Set (MDS), showed a diagnosis of bipolar disorder and severe cognitive impairment. The care plan also reflected the presence of bipolar disorder and the use of psychotropic medications. Despite these updates to the resident's medical condition, the facility did not update or resubmit the PASARR Level I to the state as required when a new diagnosis of mental illness is identified after admission. Interviews with facility staff, including the DON and Administrator, confirmed that the process for updating the PASARR was not followed for this resident after the new diagnosis was made.
Failure to Document Offer of Pneumonia Vaccine
Penalty
Summary
The facility failed to ensure that a resident's medical record included documentation that they were offered the pneumonia vaccine, as required by facility policy. The policy specified that the pneumonia immunization should be offered at admission if there was no history of prior immunization, and that immunization should be administered unless medically contraindicated or refused by the resident or their legal representative. Review of the resident's records showed no indication that the pneumonia vaccine was offered or administered, and there was no documentation of consent or refusal. The resident in question had a history of dementia and chronic obstructive pulmonary disease and was assessed as having moderate cognitive impairment. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed that the consent process for the pneumonia vaccine had not been completed for this resident. The IP stated that the consent form had been mailed out but was not returned, and the DON explained that the facility typically sent letters and educational materials to responsible parties to obtain consent. Despite these procedures, there was no documentation in the resident's record to show that the vaccine was offered or that consent or refusal was obtained.
LPN Used Profanity in Presence of Resident with Dementia
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) used profanity in the presence of a resident with severe dementia and agitation. The resident, who had a history of behavioral issues and was rarely or never understood, became combative during a blood sugar check. Witness statements from two Certified Nurse Aides (CNAs) indicated that the LPN called the resident a derogatory term and used additional profane language while attempting to obtain a finger stick, after the resident resisted and spilled juice on the LPN. The incident was observed by staff, who reported hearing the LPN use inappropriate language directed at or around the resident. The resident was assessed after the event and was found to be in a pleasant mood, with no injuries and no recollection of the incident. The LPN admitted to possibly using profanity under his breath but could not recall the exact words. Multiple staff interviews confirmed the use of inappropriate language in the resident's presence. The facility's policy requires staff to behave professionally and appropriately, especially when working with the nursing home population. The LPN's actions violated this policy, as staff are expected to maintain control of their behavior and treat residents with respect and dignity. The use of profanity in the presence of a resident, particularly one with cognitive impairment, constituted a failure to honor the resident's right to a dignified existence and respectful treatment.
Failure to Provide Privacy Bag for Resident's Catheter
Penalty
Summary
The facility failed to ensure the privacy and dignity of a resident, identified as R178, by not providing a privacy bag for the resident's catheter bag. R178 was admitted with multiple diagnoses, including paroxysmal atrial fibrillation, depression, chronic heart failure, and urinary retention, and was cognitively intact with a BIMS score of 15 out of 15. Despite the facility's policy requiring the maintenance of patient privacy and dignity, observations on two separate occasions revealed that R178's foley catheter bag was not covered with a privacy bag. Interviews with facility staff, including a CNA, LPN, RN, and the ADON, confirmed the expectation that a privacy bag should be used to maintain the dignity of residents with foley catheters, regardless of their location within the facility. However, it was verified that R178's catheter bag was not covered, indicating a failure to adhere to the facility's policy and compromising the resident's right to privacy and dignity.
Failure to Document Code Status Orders for Residents
Penalty
Summary
The facility failed to ensure that two residents, R73 and R96, had a physician's order for their code status, which is a critical component of honoring residents' rights to make decisions about their care, including advance directives. Upon review, it was found that both residents were admitted with significant medical conditions, including acute respiratory failure and depression, but did not have documented physician orders for their code status. The facility's policy requires that a physician's order be obtained and documented for code status decisions, but this was not initially done for these residents. During the survey, it was discovered that the code status orders for both residents were only updated on the day of the survey, indicating a lapse in following the facility's procedures. Interviews with the Assistant Director of Nursing (ADON) revealed that there was confusion regarding the process, as the Code Status form was mistakenly considered sufficient without a physician's order. The Administrator also indicated that there was a misunderstanding about the timeline for obtaining a physician's order, which contributed to the oversight. This deficiency highlights a failure in the facility's process to ensure timely and accurate documentation of residents' code status, as required by their own policy.
Improper Medication Storage for a Resident
Penalty
Summary
The facility failed to ensure proper storage of medications for a resident, identified as R73, which was observed during a survey. The facility's policy requires that medications be given per physician's order and that residents may self-administer medications only after a thorough assessment and approval by the interdisciplinary team. However, during an observation, Systane Hydration drops were found on R73's overbed table without a physician's order. Additionally, Tums Chewy Bites were discovered in the resident's drawer, also without an order. The resident, R73, who had a BIMS score indicating intact cognition, stated they did not know where the eye drops came from and mentioned they could be purchased over the counter. Interviews with facility staff, including an LPN and the Assistant Director of Nursing (ADON), confirmed that medications should not be left at the bedside unless the resident has been assessed and approved for self-administration. The ADON emphasized that even over-the-counter medications should not be left at the bedside without an order, and it is not acceptable for family members to leave medications in the resident's room. The facility's failure to adhere to its medication storage policy resulted in the presence of unauthorized medications in R73's room.
Deficiencies in Respiratory Equipment Management
Penalty
Summary
The facility failed to properly store and label respiratory equipment for three residents, leading to deficiencies in respiratory care. Resident 73, who was admitted with acute respiratory failure and hypoxia, was observed with unlabeled oxygen tubing and an uncovered oxygen tank. The Licensed Practical Nurse (LPN) confirmed the tubing was not labeled and the tank should have been covered. The Assistant Director of Nursing (ADON) stated that oxygen tubing should be changed weekly and dated, which was not done in this case. Resident 99, admitted with acute respiratory failure and other respiratory conditions, also had issues with unlabeled oxygen tubing. Observations revealed that the tubing was not dated, and the resident confirmed it was changed weekly. The LPN verified the tubing should have been dated, and the ADON reiterated the facility's policy of weekly changes and dating of tubing. Resident 263, with chronic obstructive pulmonary disease and respiratory failure, had a nebulizer mask that was not stored in a bag and was not changed as per the weekly schedule. The mask was dated incorrectly, indicating it had not been changed on the last scheduled date. The Registered Nurse (RN) confirmed the mask should have been changed and dated, and the ADON verified the facility's policy for weekly changes and proper dating of respiratory equipment.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to its policies regarding the labeling and storage of medications, as well as ensuring that medications were not expired, across three of the four units observed. During an observation of the medication room in one unit, it was found that the medication refrigerator checklist had five days where the temperature was not recorded. Additionally, expired items such as Cotton Tipped Applicators and Vitamin D bottles were found, which the registered nurse confirmed should have been removed and either destroyed or returned to the pharmacy. In another unit, a bottle of Tuberculin Purified Protein Derivative was found to be expired, and several vacutainers were also past their expiration dates. An unlabeled bottle containing an unknown substance was discovered, which the nurse identified as likely being betadine, and acknowledged it should have been labeled. In a third unit, a control solution was found without an open date, which the licensed practical nurse confirmed should have been dated upon opening. The Interim Director of Nurses stated that all medications and treatments should be labeled and within date, and that the refrigerator temperatures should be checked daily to ensure they are within the required range.
Inadequate Sanitary Practices During Meal Service
Penalty
Summary
The facility failed to ensure that meal trays were served under sanitary conditions, as observed during a survey. Certified Nursing Assistant (CNA)5 was seen passing meal trays in the lower number 200 hall, with her hair touching the tops of the items on each tray. This unsanitary practice continued for all the meal trays she delivered. Additionally, after touching her hair, CNA5 did not sanitize her hands before handling the meal trays. Furthermore, CNA5 put on gloves to assist a resident in bed but did not remove the gloves before feeding the resident, which is against the facility's hand hygiene policy. Interviews with staff revealed awareness of the proper procedures that were not followed. CNA5 acknowledged that she was supposed to tie her hair back and sanitize her hands after touching her hair, but her rubber band broke. Registered Nurse (RN)1 confirmed that it was inappropriate for CNA5's hair to touch the meal trays and that she should sanitize her hands after touching the trays. The Interim Director of Nurses also stated that staff are expected to pull their hair up when passing meal trays or providing care and should wash their hands after touching their hair.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R20, from verbal abuse by a Certified Nursing Assistant (CNA). R20, who was admitted with diagnoses including essential hypertension, muscle weakness, anemia, chronic systolic congestive heart failure, and mild dementia, was reported to have been verbally abused by a CNA. The incident came to light when R20's daughter reported that her mother was upset after a CNA allegedly told her, "She wished she would go home and die." This was corroborated by R20, who repeated the statement to both her daughter and facility staff, indicating a clear instance of verbal abuse. Interviews with various staff members, including the Interim Director of Nursing (IDON), Social Worker (SW), Licensed Practical Nurse (LPN), and the Director of Nursing (DON), confirmed that the incident was reported but not initially classified as abuse. The CNA involved was terminated for poor customer service rather than for the abuse allegation. Despite the facility's policy against abuse and the requirement to report such incidents, the CNA was not reported for abuse, highlighting a failure in the facility's obligation to protect residents from verbal abuse and to follow proper reporting procedures.
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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) |
|---|---|---|---|---|
| Retreat At Wellmore Of Lexington | 2.1 mi | ★★★★★ | 0 | 0 |
| Presbyterian Home Of South Carolina-columbia | 6.8 mi | ★★★★★ | 0 | 0 |
| Nhc Healthcare - Lexington | 7.3 mi | ★★★★★ | 1 | 0 |
| St Andrews Operator, Llc | 7.4 mi | ★★★★★ | 0 | 0 |
| Opus Post Acute Rehabilitation | 8.1 mi | ★★★★★ | 1 | 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.