Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Lexington Post Acute during CMS and state inspections, most recent first.
Unsecured Resident Medication Found in Walker: A resident’s Fluticasone nasal spray was found in her walker during med pass when an LPN could not locate it on the med cart. The resident stated she kept the Flonase in her walker and used it once daily, and the LPN assisted with administration. The resident had vascular dementia, auditory hallucinations, and cognitive communication deficit, and staff stated there was no evaluation showing she was approved to self-administer or store the medication on her own.
PBJ staffing data was not submitted accurately because weekend staffing was reported at excessively low levels. Review of the facility’s PBJ report and licensure staffing requirements showed multiple weekends with staffing percentages between 2.14% and 3.12%. The Administrator stated that higher census and acuity were present and that on-call staff came in, but if payroll codes were not changed, the staffing would not be captured correctly and would not reflect accurate staffing.
Infection control was not maintained during incontinence care, wound care, and medication administration. An LPN texted a physician from a personal cell phone and then handled meds without hand hygiene, two CNAs placed soiled incontinent linen on the floor instead of bagging it, and a wound care nurse changed gloves without cleaning hands between glove changes. The DON and ADON acknowledged the expected hand hygiene and linen handling practices.
The facility failed to inform residents about their rights to refuse treatment and formulate advance directives, affecting 11 residents with various medical conditions. Despite the facility's policy, the required sections of the Consent and Authorizations forms were not initialed, indicating a lack of information provided. The administrator confirmed this oversight, highlighting a systemic issue in the facility's process.
The facility failed to maintain sanitary conditions in its food service operations, with unsanitary kitchen conditions and inadequate dishwashing practices. Observations revealed dirt, debris, and food particles on containers, a greasy oven and vent hood, and rusty utensil drawers. The dish machine consistently failed to reach the required sanitation temperature, and the facility lacked sufficient emergency food stock. These issues were confirmed by the Dietary Manager and Registered Dietitian.
A resident with multiple diagnoses, including COPD, was left unattended with a running nebulizer, contrary to facility policy requiring nurse supervision during medication administration. The resident, who was cognitively intact, had no evaluation for self-administration of medication, as confirmed by the DON.
A resident reported a sexual assault by a CNA during a bed bath, but the facility failed to report the allegation to the appropriate authorities as required by policy. The Administrator conducted an initial investigation before deciding not to report, contrary to the policy of immediate reporting within two hours.
A resident reported a sexual abuse allegation against a CNA, but the facility failed to conduct a thorough investigation as per its policy. The investigation lacked detailed documentation and did not include all required interviews and reviews. The Administrator believed the steps taken were sufficient, despite the incomplete investigation process.
Two residents did not receive scheduled showers as per the facility's policy, leading to a deficiency in care. One resident, moderately cognitively impaired, missed multiple showers over several weeks, while another, cognitively intact, reported receiving showers only every two weeks. The DON confirmed the lapses in scheduled care.
A facility failed to follow infection control practices when a nurse did not wear PPE during medication administration via peg tube for a resident under enhanced barrier precautions, and a CNA did not perform hand hygiene during catheter care for a cognitively impaired resident. The DON confirmed the lapses in protocol adherence.
The facility failed to employ a qualified dietician, leading to deficiencies in kitchen sanitation, staff competencies, and meal delivery. Residents did not receive meals that met their dietary needs, with reports of late, incomplete, or inadequate meals. The kitchen was found in poor sanitary condition, with untrained staff performing duties due to a lack of leadership and consistent staffing.
The facility failed to provide sufficient and properly trained staff for its food and nutrition services, leading to incomplete dish machine logs and late meal deliveries. The Administrator and other non-dietary staff had to work in the kitchen due to understaffing, resulting in disorganized operations. Residents reported receiving meals late, and many staff members lacked the necessary training to perform kitchen duties effectively.
The facility's kitchen was found to be unsanitary, with dietary staff not covering facial hair, dirty floors, and unclean equipment. Dish machine temperatures and sanitizer levels were not consistently checked or recorded, and cleaning schedules were not followed. Interviews with staff revealed a lack of leadership and accountability in maintaining cleanliness.
The facility failed to provide a nourishing and well-balanced diet to its residents, as evidenced by three residents not receiving meals that met their nutritional needs. A resident at risk for weight loss did not receive prescribed double portions, and the facility was unable to provide menu items due to a delay in food delivery. Staff and residents reported issues with meal quality, portion sizes, and late meal delivery, highlighting disorganization and staffing issues in the kitchen.
Unsecured Resident Medication Found in Walker
Penalty
Summary
Medications were not properly stored when a resident’s Fluticasone nasal spray was found unsecured in the resident’s walker during medication administration. Facility policy stated that drugs and biologicals are to be stored in a safe, secure, orderly manner in locked compartments, and controlled drugs in separately locked compartments. During observation on the 200 Hall, an LPN could not locate the resident’s Fluticasone on the medication cart, and the resident stated that the Flonase was in her walker and that she used it once per day. The resident removed the nasal spray from the seat of the walker and gave it to the LPN, who then assisted with administration. The resident involved had diagnoses including vascular dementia, auditory hallucinations, cognitive communication deficit, and need for assistance with personal care. The quarterly MDS indicated a BIMS score of 14, and the resident required setup assistance with eating, oral hygiene, and personal hygiene, with supervision to touching assistance for bathing. The order summary showed an order for Fluticasone nasal spray for seasonal allergic rhinitis. When asked about self-administration, the LPN stated there was nothing in the evaluations, and the DON also stated there was no evaluation in the computer system. The DON stated that medication should not be stored in a resident’s room unless the resident had been evaluated to use the medication safely on her own, and stated she was not aware the resident was storing the nasal spray in her walker.
PBJ Staffing Data Reported Inaccurately
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS through the PBJ system based on payroll and other verifiable and auditable data. Review of the facility policy titled, Reporting Direct Care Staffing Information (Payroll-Based Journal), showed that direct care staffing information is to be reported electronically to CMS in a uniform format and includes staff hired directly by the facility, agency staff, and contract employees. Review of the PBJ Staffing Data Report for Quarter 4 of 2025 showed excessively low weekend staffing. Review of LICENSURE STAFFING REQUIREMENTS for multiple weekend dates between July 1, 2025 and September 30, 2025 showed weekend staffing percentages ranging from 2.14% to 3.12%. During an interview on 2/12/2026 at 11:47 AM, the Administrator stated that higher census and acuity level were present and that on-call staff were coming in, but if payroll codes were not changed, the staffing would not be captured correctly and would not reflect accurate staffing.
Infection Control Lapses During Incontinence Care, Wound Care, and Medication Administration
Penalty
Summary
Provide and implement an infection prevention and control program was not maintained during incontinence care, wound care, and medication administration for three sampled residents. Facility policy stated soiled laundry and bedding should be handled as potentially contaminated using standard precautions, bagged or contained at the point of collection, and that hand hygiene is required immediately after glove removal. During medication administration for a resident with Alzheimer’s disease, type 2 diabetes mellitus, dementia, dysphagia, and GERD, an LPN could not find the ordered lidocaine patch, texted the physician from her personal cell phone, and then proceeded to pull medications for the next resident without sanitizing her hands after using the phone. The DON stated a nurse should wash her hands after using a personal phone. During incontinent care for a resident with Alzheimer’s disease, cognitive communication deficit, need for assistance with personal care, and reduced mobility, two CNAs prepared to provide care and one removed the soiled cloth incontinent pad and gown and placed them on the floor instead of bagging or containing them. The CNAs acknowledged the linen should have been placed in a bag or pillowcase, and the ADON stated soiled linen should have been bagged before transport to the soiled cart. During wound care for a resident with alcohol dependence with withdrawal, delirium, and muscle weakness, the wound care nurse performed hand hygiene, donned PPE, cleansed the wound, changed gloves multiple times, and failed to wash or sanitize hands after removing gloves and before donning clean gloves. The DON stated hand hygiene should be performed between glove changes, and the wound care nurse stated hand hygiene should be done before, after, and between glove changes.
Failure to Provide Advance Directive Information to Residents
Penalty
Summary
The facility failed to provide information to residents regarding their right to refuse medical or surgical treatment or to formulate an advance directive. This deficiency was identified for 11 out of 24 residents reviewed for advance directives. The facility's policy, dated September 2022, requires that the social services director or designee inquire about the existence of any written advance directives upon admission and provide written information concerning the right to refuse or accept treatment and to formulate an advance directive. However, the review of medical records revealed that the required sections of the Consent and Authorizations forms were not initialed or signed, indicating that residents or their representatives were not given the necessary information or assistance regarding advance directives. The deficiency involved residents with various medical conditions, including rheumatoid arthritis, atrial fibrillation, heart failure, hypertension, dementia, anxiety, depression, Alzheimer's disease, multiple sclerosis, and traumatic brain injury. The cognitive status of these residents varied, with some being cognitively intact and others severely impaired, as indicated by their Brief Interview for Mental Status (BIMS) scores. Despite these differences, the facility consistently failed to document that residents or their representatives received education about advance directives, as evidenced by the lack of initials on the Consent and Authorizations forms. During an interview, the facility's administrator confirmed that the Consent and Authorizations forms should have been initialed to indicate that residents or their responsible parties received education about advance directives. This oversight highlights a systemic issue in the facility's process for ensuring that residents are informed of their rights regarding medical treatment and advance directives, as required by their own policy.
Sanitation and Food Service Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in its food service operations, as evidenced by multiple observations and policy reviews. The kitchen was found to have unsanitary conditions, including dirt, debris, and dead insects on food cartons, sticky and dirty containers, and food particles on the outside of containers. The oven and grease trap were observed with significant build-up of grease and food particles, and the vent hood was greasy and dirty. Additionally, utensils were stored in rusty drawers, and food items were undated and unlabeled in dirty containers. These conditions were confirmed by the Dietary Manager and Registered Dietitian, who acknowledged that the kitchen should not be in such a state. Furthermore, the facility's dishwashing practices were inadequate, with the low temperature dish machine consistently failing to reach the required 120 degrees Fahrenheit for proper sanitation. The dish machine logs showed repeated instances of wash temperatures below the required level, and staff failed to cease use of the machine despite these inadequate temperatures. Additionally, the facility did not have sufficient food stock for a 72-hour emergency menu, as confirmed by the Registered Dietitian, who noted missing food items and the need to order additional supplies. These deficiencies indicate a failure to adhere to professional standards for food storage, handling, preparation, and service.
Failure to Supervise Medication Administration
Penalty
Summary
The facility failed to assess a resident for self-administration of medication, specifically concerning the use of a nebulizer. The facility's policy on administering medications through a nebulizer requires a nurse to be present during the administration and to ensure the nebulizer is turned off and put away after use. However, observations revealed that the resident was left unattended with the nebulizer running in their lap for an extended period, indicating a lack of supervision and adherence to the facility's policy. The resident involved was admitted with multiple diagnoses, including Rheumatoid Arthritis, Atrial Fibrillation, Heart Failure, and Hypertension, and was cognitively intact with a BIMS score of 15. The resident had a physician's order for Ipratropium/Albuterol inhalation solution to be administered four times a day for Chronic Obstructive Pulmonary Disease. Despite this, the Director of Nursing confirmed that there was no evaluation for the resident's ability to self-administer medication, and a nurse should have been present during the administration.
Failure to Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to all appropriate local and state agencies. According to the facility's policy, any reports of resident abuse must be reported to local, state, and federal agencies within two hours of the allegation. However, the facility did not adhere to this policy when a resident, who was cognitively intact and dependent on staff for personal care, reported a sexual assault by a Certified Nursing Assistant (CNA) to the Assistant Director of Nursing (ADON). The resident alleged inappropriate touching during a bed bath, which was not reported to the necessary authorities as required. The Administrator, who also served as the Abuse Coordinator, confirmed that an initial investigation was conducted before any report was made to the State Agency. The Administrator's interpretation of a 'true allegation' required a suspicion to be confirmed before reporting, which led to the failure to report the incident immediately. The CNA involved denied the allegations, and the resident was appeased by removing the CNA from her care. This approach was contrary to the facility's policy, which mandates immediate reporting of any abuse allegations, regardless of the initial investigation's findings.
Inadequate Investigation of Sexual Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of sexual abuse involving a resident who was cognitively intact and dependent on staff for various activities. The resident reported to the Assistant Director of Nursing (ADON) that a Certified Nursing Assistant (CNA) had inappropriately touched her during a bed bath. The facility's policy requires a comprehensive investigation, including interviews with the resident, the accused, and any witnesses, as well as a review of the resident's medical records and interactions. However, the investigation was insufficient, as evidenced by the lack of a detailed and dated documentation of the investigation process. The Administrator provided a one-page undated witness statement and additional documents that did not meet the facility's policy requirements for a thorough investigation. The Administrator admitted to interviewing the resident and the CNA and instructed the CNA to avoid the resident's room, but there was no evidence of a complete investigation as outlined in the policy. The Administrator's response indicated a belief that the steps taken were appropriate, despite the lack of comprehensive documentation and adherence to the facility's policy on abuse investigations.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL), specifically showering, for two residents. According to the facility's policy, residents who cannot independently perform ADLs should receive necessary services to maintain personal hygiene. However, Resident #41, who was moderately cognitively impaired and required partial assistance with bathing, did not receive showers on multiple scheduled dates in January and February 2025. This was confirmed by the resident, who kept a personal record of her shower dates and reported not receiving a shower for two weeks in January. Similarly, Resident #45, who was cognitively intact and also required partial assistance with bathing, reported receiving showers only every two weeks, contrary to the facility's schedule of three times a week. The Director of Nursing confirmed that residents should receive showers on their assigned dates and acknowledged the missing dates. These findings indicate a failure to adhere to the facility's policy on providing necessary ADL assistance, resulting in a deficiency in resident care.
Infection Control Lapses During Medication and Catheter Care
Penalty
Summary
The facility failed to adhere to its infection control practices during medication administration and catheter care, as observed in two separate incidents. In the first incident, a Registered Nurse (RN) did not wear the required personal protective equipment (PPE) while administering medication via a peg tube to a resident who was under enhanced barrier precautions. This resident had a medical history that included Wernicke's Encephalopathy, Diabetes, Dysphagia, Gastrostomy, and Respiratory Failure, and was assessed for a feeding tube. The facility's policy required the use of gloves and gowns for such procedures, but the RN was observed administering medication without a gown. In the second incident, a Certified Nursing Assistant (CNA) failed to perform hand hygiene during foley catheter care for a resident with a history of Heart Failure, Multidrug-Resistant Organism, Urinary Tract Infection, Malnutrition, and Diabetes. The resident was severely cognitively impaired and dependent on staff for various activities. The CNA was observed removing soiled gloves and donning new ones without performing hand hygiene, contrary to the facility's hand hygiene policy. The Director of Nursing confirmed that the staff should have adhered to the infection control protocols in both cases.
Deficiencies in Dietary Services and Kitchen Sanitation
Penalty
Summary
The facility failed to employ a Registered Dietician (RD) or Qualified Nutritional Professional to oversee the food and nutrition services, leading to significant deficiencies in kitchen sanitation, staff competencies, and the timely delivery of meals. The absence of a qualified professional resulted in inadequate oversight of kitchen operations, including the failure to maintain proper cleaning and sanitizing protocols, as evidenced by incomplete dish machine temperature logs and unperformed cleaning duties. Additionally, the facility's policies regarding dietary services, such as ensuring meals meet residents' nutritional needs and are delivered on time, were not adhered to. The report highlights several instances where residents did not receive meals that met their prescribed dietary needs. For example, a resident with a history of weight loss and a regular diet order with double portions did not receive the appropriate meal portions due to a lack of food availability and staff shortages. Observations revealed that meals were often late, incomplete, or substituted with inadequate alternatives, such as missing menu items like waffles and chocolate chip cookies. Interviews with residents and staff confirmed ongoing issues with meal quality and timeliness, exacerbated by the facility's inability to maintain consistent kitchen staffing and leadership. Furthermore, the facility's kitchen was found to be in poor sanitary condition, with observations of dirty floors, unclean equipment, and staff not adhering to hygiene protocols, such as wearing facial coverings. The lack of a Certified Dietary Manager (CDM) and the reliance on untrained staff, including the Administrator and housekeeping personnel, to perform kitchen duties contributed to the disorganization and failure to meet regulatory standards. The facility's inability to provide adequate training and maintain a clean and organized kitchen environment further compromised the quality of care provided to residents.
Staffing and Training Deficiencies in Food and Nutrition Services
Penalty
Summary
The facility failed to provide sufficient staff with the necessary competencies and skill sets to effectively carry out the functions of the food and nutrition services. This deficiency was observed in 12 out of 17 staff members, including dietary aides, CNAs, housekeepers, and even the Director of Nursing and the Administrator, who were working in the kitchen. The facility had a census of 78 residents, with 76 receiving meal trays from the kitchen. The lack of trained staff led to incomplete dish machine temperature logs and sanitizer checks, as well as late meal deliveries. Observations and interviews revealed that the facility's kitchen was understaffed and lacked proper leadership following the firing of the previous Certified Dietary Manager in September 2024. The Administrator had to step in to work in the kitchen, logging 600 hours, and even purchasing food from Walmart due to delivery issues. Meal times were consistently late, with reports of breakfast being served as late as 9:00 AM, lunch at 2:00 PM, and supper at 6:30 PM. Residents confirmed that their meals were often delayed, with one resident stating that lunch was served as late as 2:00 PM. The deficiency was further compounded by the fact that many staff members working in the kitchen were not officially trained for their roles. Housekeepers and CNAs were asked to assist in the kitchen, but they lacked the necessary training to perform tasks such as checking dish machine temperatures and using sanitizer strips. The Director of Nursing and the Administrator confirmed that the kitchen staff was not fully trained, and the absence of a Certified Dietary Manager led to a lack of leadership, resulting in disorganized operations and late meal services.
Sanitation and Food Handling Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by multiple observations of unclean equipment and improper food handling practices. Dietary staff were observed not wearing facial coverings to cover facial hair, and the kitchen floor was consistently dirty with scattered paper and debris. Additionally, cookware, including skillets and pans, had significant black sticky buildup, and the convection oven contained dried food particles and a thick brown sticky substance. Metal storage racks were found to be rusty with peeling metal and dust buildup. The facility also failed to adhere to its own policies regarding dishwashing and sanitation. The dish machine temperature logs for November and December 2024 were incomplete, with numerous instances where temperatures and sanitizer levels were not checked or recorded. This lack of documentation was confirmed by the Administrator, who was unable to locate the kitchen sanitation logs for September and October 2024. Furthermore, the cleaning schedule for the kitchen was not followed, with multiple blank areas indicating that cleaning duties were not performed by the AM aide, cook, and PM aide on numerous days. Interviews with various staff members, including the Certified Dietary Manager (CDM) from another facility, the Housekeeping and Laundry Supervisor, the Director of Nursing (DON), and a Certified Nursing Assistant (CNA), revealed a lack of leadership and accountability in maintaining kitchen cleanliness. The CDM acknowledged the presence of bad habits and the need for constant supervision to ensure adherence to cleaning schedules. The DON and Administrator confirmed that the kitchen was not clean and that dish machine temperatures and sanitizer levels should be checked and documented regularly.
Failure to Provide Adequate Nutrition and Meal Portions
Penalty
Summary
The facility failed to provide a nourishing and well-balanced diet that meets the daily nutritional and dietary needs of its residents. This deficiency was observed in three residents who were reviewed for nutrition. The facility's policy on dietary menus and adequate nutrition was not adhered to, as evidenced by the failure to provide meals that met the nutritional needs of the residents. Resident #2, who was at risk for weight loss, did not receive the prescribed double portions of meals, and the facility was unable to provide the menu items due to a delay in food delivery. The resident expressed concerns about the quality and consistency of meals, and the facility's inability to provide the prescribed diet was confirmed by staff observations and interviews. The facility's kitchen operations were disorganized, leading to inconsistencies in meal preparation and delivery. Observations revealed that residents did not receive the menu items as planned, and substitutions were made due to a lack of available food. Staff interviews confirmed that residents received smaller portions than prescribed, and the facility struggled with staffing issues in the kitchen. The lack of a dietary manager and consistent kitchen staff contributed to the failure to meet the residents' nutritional needs. Interviews with staff and residents highlighted ongoing issues with meal quality and portion sizes. Residents reported receiving meals late and expressed dissatisfaction with the food provided. Staff confirmed that the facility did not have enough food to meet the prescribed portions, and the Director of Nursing acknowledged the need for better kitchen management and planning. The Administrator confirmed that there were complaints about food shortages and that efforts were made to address the issue temporarily by purchasing groceries. However, the deficiency persisted, affecting the residents' nutritional intake and overall satisfaction with the facility's dietary services.
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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) |
|---|---|---|---|---|
| Briarwood Community Living Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Decatur County Healthcare | 14.4 mi | ★★★★★ | 2 | 0 |
| Westwood Nursing And Rehabilitation | 14.6 mi | ★★★★★ | 0 | 0 |
| Henderson Health And Rehabilitation Center | 21.6 mi | ★★★★★ | 6 | 0 |
| Laurelwood Health Care Center | 22.9 mi | ★★★★★ | 5 | 1 |
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