Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Heritage Hall Lexington during CMS and state inspections, most recent first.
Grievance information was not posted or made readily available, and residents and staff were unclear who the grievance officer was or how to file concerns. The facility had shifted to a QR code-based process that residents were not told about, and several staff members said they had not been educated on it. The facility also mishandled a resident grievance involving a rushed transfer and shoulder impact, with conflicting accounts about whether the DON knew of the incident or educated the CNA involved.
Failure to Complete Required Pre-Employment Screening: The facility did not follow its abuse prevention and hiring policies for five of 25 employee records reviewed. One employee had no reference checks, another had incomplete reference checks, two nurses had license findings that were not reviewed, and a dietary employee with a confirmed felony barrier crime was hired. Interviews showed HR staff did not fully review license verification details, and the DON had not been given files to review.
Expired OTC meds were found in the med room and on the pink hall med cart, including Oyster shell calcium and fiber laxative capsules. An accessed lidocaine HCl vial had no open date, and the med storage refrigerator thermometer read 26 degrees Fahrenheit with a cracked thermometer, while the DON stated staff should check med dates routinely and opened vials should be dated.
Food items in the main kitchen and unit pantry were found improperly labeled, dated, and stored. During observation with the DM present, multiple opened foods in the freezer, dry storage, cooler, and prep area had missing or unclear open/use-by dates, and one staff member’s personal beverage was stored in a food cooler. In the unit pantry, expired hot dog buns and corn flakes were also found. The DM acknowledged the dating system was confusing and removed the expired items when shown to him.
Care plans were not kept current for two residents. One resident’s plan still listed a healed Stage 4 pressure injury even though the wound was no longer present and the MDS showed no pressure wounds. Another resident’s plan did not reflect the use of coffee mugs or other assistive devices during meals, despite a physician order and observed difficulty handling a glass of milk.
Failure to follow physician orders affected two residents. One resident with ESRD and impaired cognition had an ordered fluid restriction, but staff did not consistently track all intake, the restriction was not on the CNA Kardex, and bedside mugs with water were observed while staff said between-meal fluids were not being monitored. Another resident with respiratory failure, COPD, and severe morbid obesity had a physician order for a bariatric bed, but the resident remained in a standard bed and the DON was unaware of the order.
A resident who needed supervision for toileting and partial to moderate assistance with transfers reported that a CNA rushed her during bathroom assistance, causing her to lose balance and hit her shoulder against the wall. The incident was not documented in nursing notes or assessed by staff at the time, and the DON, nurses, and CNAs working that day were unaware of it until later, while the NP believed staff already knew about the event.
Oxygen Therapy Not Administered Per Physician Order: A resident's oxygen was repeatedly observed set above the ordered 8 L/min, including 8.5, 9, and 10 L/min. The resident said the oxygen was sometimes "too much," and an LPN confirmed the setting was incorrect. The chart and care plan ordered 8 L/min via high-flow nasal cannula with pulse ox checks every 4 hours, and oxygen could only be increased to 10 L/min if sats fell below 88%.
Failure to document response to a pharmacy recommendation for a resident receiving trazodone. The resident had multiple chronic conditions including dementia, Parkinson's disease, CKD, AFib, and dysphagia, and trazodone 25 mg was ordered for afternoon agitation and given daily at 5:00 p.m. The pharmacist noted the medication could increase sedation and fall risk and suggested bedtime dosing unless contraindicated, but the chart contained no physician response; an ADON note only stated it was given specifically at 1700 for agitation, and the NP did not reference the recommendation.
Missed Physician-Ordered PT-INR: A resident’s physician-ordered PT-INR was not obtained on the scheduled day. The DON stated the lab was not completed as planned and there were no results available at that time. The resident’s care plan directed staff to obtain labs as ordered, and facility policy stated staff were responsible for arranging tests and documenting communication in the resident record.
A resident ordered a mechanical soft diet with meats served with gravy or sauce was observed receiving sausage without gravy or sauce, and the meat appeared dry. The meal ticket listed ground meat with gravy, the resident pointed at the sausage and said no, no, and the RP reported concerns that meals were not resident-centered and that meats were dry. A CNA was unsure about the gravy, while the Dietary Mgr stated the ticket should be followed because it reflected the physician’s order.
Failure to provide ordered meal assistance and adaptive drinking equipment. A resident on a mechanical soft diet was observed at breakfast without drinks served in coffee mugs, despite meal ticket and MD orders directing that all drinks be served in coffee mugs and meats be served with gravy or sauce. The resident had difficulty picking up a glass of milk and stated he needed handles, while the CNA and Dietary Mgr confirmed that meal tickets with these directions were to be followed.
Hand hygiene was not followed during a medication pass on Sunset Drive when an LPN washed her hands after giving meds to one resident, directly touched the faucet handle to turn off the water before drying her hands, and then prepared meds for another resident. The DON stated staff should use a dry paper towel to turn off the faucet, and the facility policy required hands to be rubbed for at least 20 seconds, rinsed, dried, and the faucet turned off with a towel.
A facility failed to maintain complete and accurate records for a resident, with significant gaps in documentation for ADL support and food intake logs. The resident, with diagnoses including post-surgical hip replacement and urinary tract infection, had incomplete records for eating performance, personal hygiene, and toilet use, as well as meal intake. The administrator acknowledged the issue and noted a need for staff training.
A resident with multiple health issues, including a femur fracture and urinary tract infection, experienced a delay in toileting assistance at the facility. The resident's call light went unanswered for over an hour, leading to the resident soiling herself. Interviews with facility staff confirmed the lack of documentation and delayed response, which was against the facility's policy on timely assistance for activities of daily living.
Grievance Process Not Posted or Communicated; Resident Grievance Not Accurately Handled
Penalty
Summary
The facility failed to ensure grievance information was posted and readily available to residents and failed to identify the designated grievance officer. During observation, no grievance forms were available for residents to submit concerns, and there was no posting of the grievance officer’s name or contact information. In resident council discussion, several residents stated they were not aware of who the grievance officer was or how to file a grievance. Staff interviews reflected confusion about the grievance process, with multiple staff members stating they did not know who the grievance officer was, had not been educated on the new process, or believed the process involved QR codes that residents would need a cell phone to use. The facility documentation reviewed included a Resident and Family Grievance Policy stating that residents and family members may voice grievances, that prompt efforts would be made to resolve grievances, that grievances could be filed verbally, in writing, or anonymously, and that the grievance official’s contact information would be posted in prominent locations. Despite this policy, the QR code-based process had not been communicated to residents, and residents reported the room postings appeared to ask only for general feedback rather than explain how to file a grievance. The social service director stated the new system required scanning a QR code with a cell phone, while the administrator acknowledged technology was not suitable for this population and said he would request approval to return to a paper process. The facility also did not implement an accurate grievance procedure for Resident #30, who had diagnoses including degenerative disease of the nervous system, carpel tunnel syndrome, muscle weakness, osteoarthritis, arthritis of the left shoulder, and unsteady gait, and was assessed as cognitively intact on the most recent quarterly MDS. A grievance dated 6/18/25 documented that a CNA rushed the resident during a bathroom transfer, causing the resident to lose balance and hit her shoulder on the wall, and it stated the DON was aware of the incident and had educated the CNA. However, during the end-of-day meeting on 8/27/25, the DON stated she had been unaware of the incident until that day, had been on vacation during the week of the incident, and had not educated the CNA, who was an agency CNA and had not worked at the facility since the incident. The administrator stated he thought the DON knew about the incident.
Failure to Complete Required Pre-Employment Screening
Penalty
Summary
The facility failed to implement its abuse prevention and background check policies for five of 25 employee records reviewed. The record review identified that one employee had no reference checks completed, another employee had two reference checks that were not completed, and two nurses had findings noted on their licenses, but the facility did not obtain information about those findings. In addition, a dietary employee disclosed a felony barrier crime on his sworn statement, the background check confirmed the barrier crime, and the facility hired him. During interviews, the Business Office Assistant stated that background checks are completed to ensure there are no barrier crimes and that license verification is used to confirm the license is current, but she also stated that if a license verification shows "yes," she prints that page and does not access the detailed information. The DON stated she expected HR staff to bring her the employee file if a license verification indicated yes so she could review what was on the license, but she had not been provided any files to review. The Administrator later acknowledged that his own file did not contain the reference checks he had provided, and the Business Office Assistant stated the employee hired with a felony barrier crime was going to be terminated and should never have been hired.
Expired and Improperly Stored Medications Found in Medication Room and Cart
Penalty
Summary
The facility failed to label and store medications appropriately in the medication room and on one medication cart. During an observation of the medication storage room, four full bottles of Oyster shell calcium 500 mg were found in the OTC cabinet with an expiration date of 6/2025, and two bottles of fiber laxative capsules were also present with an expiration date of 7/25. The medication storage refrigerator had an internal thermometer reading 26 degrees Fahrenheit, and the nurse confirmed that this temperature would freeze the medications and immunizations stored in the refrigerator. The thermometer was cracked, and the accuracy of the reading was uncertain, although the temperature log showed a recorded temperature of 38 degrees earlier that day. During inspection of the pink hall medication cart, a vial of lidocaine HCl 1% had been accessed but had no open date, and an expired bottle of fiber laxative capsules with an expiration date of 7/25 was available for administration. The LPN present confirmed the capsules were expired and stated that expired medications were an infection control issue. Facility policy required OTC bulk containers to include expiration dates, opened multi-dose vials to be dated and discarded within 30 days unless otherwise specified, and outdated or deteriorated medications to be removed from stock. The DON stated that the medical records employee should check dates in the medication storage room at least weekly and that nurses should check medications in carts daily.
Food Storage and Labeling Deficiencies in Kitchen and Unit Pantry
Penalty
Summary
The facility failed to store and prepare food in a sanitary manner in the main kitchen and the unit pantry. During observation of the main kitchen with the dietary manager present, multiple food items were found without clear dating or labeling, including opened meatballs, manicotti, spaghetti noodles, elbow macaroni, sweet cornbread muffin mix, sliced tomatoes, banana cream pie, a cut cucumber, and a staff member’s personal beverage bottle. Several items had no visible date of when they were opened or when they were to be used by, and the dietary manager stated that some dates had been torn off or were confusing to interpret. Additional observations in the kitchen showed bulk food containers and dry storage items with inconsistent or unclear date markings. Two containers of food thickener had an open date of 7/25 and a use by date of 1/25, which the dietary manager could not explain as either month/day or month/year. Other items, including opened powdered sugar, brown gravy powder mix, and brown sugar, also had missing, unclear, or inconsistent open and use-by dates. The dietary manager acknowledged that the dating system was confusing and left a lot to interpretation, and that it was not possible to know whether the dates represented month and day or month and year. In the unit pantry, a bag of hot dog buns had a best-by date of 8/20/25 and a bowl of corn flakes had a label showing CF 8/15 and UB 8/23. The dietary manager later observed these expired items in the pantry and removed them, stating he did not know where the hot dog buns had come from. Facility policy required opened foods to be dated and sealed, foods to be labeled with the common name and date prepared or expiration date, and foods past expiration or use-by dates to be discarded. The administrator was informed of the findings, and no additional information was provided.
Care Plans Not Updated to Reflect Current Resident Needs
Penalty
Summary
The facility failed to review and revise comprehensive person-centered care plans for two residents. For one resident, the care plan revised on 5/9/25 continued to identify a Stage 4 pressure ulcer even though the wound had healed in March 2025 and the Minimum Data Set completed on 6/18/25 documented no pressure wounds. During an interview, the resident stated he did not have any open wounds and that previous wounds had healed. The DON confirmed the wound was healed and acknowledged that the care plan was incorrect. For another resident, the comprehensive care plan did not reflect the use of assistive devices during meals. During a meal observation, liquids were not provided in coffee mugs as indicated on the meal ticket, and the resident had difficulty picking up a glass of milk. The resident stated he needed handles. The clinical record showed a physician order dated 8/26/25 for all drinks to be provided in coffee mugs, but the care plan did not include this support for meals or for the resident’s ability to consume liquids safely.
Failure to Follow Physician Orders for Fluid Restriction and Bariatric Bed
Penalty
Summary
The facility failed to follow physician orders for Resident #17’s ordered fluid restriction. The resident had diagnoses including end stage renal disease, metabolic encephalopathy, glaucoma, epilepsy, dysphagia, anemia, and diabetes, and the MDS assessed moderately impaired cognitive skills. A physician order dated 8/14/25 directed a 1500 ml per day fluid restriction, with 4 oz. to be given four times daily with medications and the remaining ounces served on the meal tray. Observation and interview showed multiple mugs and cups with water and tea at the bedside, while the resident stated staff filled the mugs and that she drank when she wanted. The MAR documented only the medication-pass fluids, and meal intake records documented some fluids with meals, but there was no documentation of other fluid intake or a daily total. Staff interviews showed the CNA was not aware of the restriction and routinely filled the resident’s mug, while the LPN was unsure whether fluid intake between meals was tracked. The DON stated the restriction should have been on the bedside Kardex and that the resident’s supplemental fluid intake should have been monitored, but between-meal intake had not been included in daily totals. The facility also failed to provide Resident #46 with a bariatric bed as ordered by the physician. The resident had diagnoses including respiratory failure, anxiety, COPD, severe morbid obesity, and fibromyalgia, and the most recent MDS showed a BIMS score of 14. The resident stated the facility had ordered a bariatric bed about a month earlier but it had not been received, and the current bed was uncomfortable and difficult to use. The clinical record contained a physician order dated 6/10/25 for a bariatric bed, and the care plan indicated a bariatric bed was in place. When the DON and nurse consultant observed the bed, the DON stated it was not a bariatric bed and later said she was unsure whether the bed had been ordered and was unaware of the physician order.
Failure to Report and Investigate Toileting Incident
Penalty
Summary
The facility failed to notify and thoroughly investigate an incident that occurred while Resident #30 was being assisted to the bathroom. Resident #30 was cognitively intact and had diagnoses including degenerative disease of the nervous system, carpel tunnel syndrome, muscle weakness, osteoarthritis, arthritis of the left shoulder, and unsteady gait. Her most recent assessments indicated she needed supervision for toileting and partial to moderate assistance for sit-to-stand and toilet transfer. During the resident interview, she stated that a CNA was helping her in the bathroom, asked her to pull up her pants while still being supported, and she lost her balance, fell against the wall, and then sat on the commode. She reported that her shoulder began hurting the next day. The clinical record did not contain nursing progress notes or assessments for the incident date. A nurse practitioner note documented that the resident reported right shoulder pain after a transfer incident in which a CNA assisted her to the bathroom and she hit her right shoulder against the wall. Staff interviews showed the DON was unaware of the incident until it was brought to her attention later, and the nurses and CNAs working that day were also unaware of any reported incident. The nurse practitioner stated she thought staff already knew about the event. The resident's daughter, who worked at the facility, reported that the resident told her the aide was rushing her during toileting and that she hit her shoulder on the bathroom wall, and she filed a grievance asking that the CNA not be assigned to her mother again.
Oxygen Therapy Not Administered Per Physician Order
Penalty
Summary
The facility failed to administer oxygen according to physician's orders for Resident #1. Observations on 8/26/25 and 8/27/25 showed the resident's oxygen set above the ordered 8 liters per minute, including 8.5 liters, 9 liters, and later 10 liters. During an interview on 8/27/25, the resident stated that the oxygen was "too much" sometimes and described staff placing a device on her finger and then turning the knobs. At 9:12 a.m. on 8/27/25, an LPN observed the oxygen set at 9 liters per minute and stated that if the resident's saturation fell below 88%, oxygen may be increased to 10 liters per minute; she also reported the resident's saturation had been checked at 5:00 a.m. and was 97%, and then rechecked at 94% when the oxygen setting was found to be incorrect. Review of the clinical record showed physician orders dated 7/24/25 for oxygen at 8 liters per minute via high-flow nasal cannula to maintain oxygen saturations at 88%, with pulse oximetry every four hours and permission to increase oxygen to 10 liters per minute if saturations fell below 88% until above 90%. The care plan contained the same instructions. Facility documentation for oxygen administration stated staff should verify the physician's order, review the order or protocol, review the care plan for special needs, and assemble the necessary equipment and supplies before administering oxygen. The administrator, DON, and corporate staff were informed of the concern during an end-of-day meeting on 8/27/25.
Failure to Document Response to Pharmacy Recommendation
Penalty
Summary
The facility failed to document a response to a pharmacy recommendation for one resident receiving trazodone. The resident had diagnoses including Parkinson's disease, diabetes, chronic kidney disease, atrial fibrillation, dementia, obstructive sleep apnea, major depressive disorder, anxiety, dysphagia, cognitive communication deficit, hypertension, and gastroesophageal reflux disease, and the MDS assessed short- and long-term memory problems with severely impaired cognitive skills. The physician ordered trazodone 25 mg each afternoon for agitation, and the MAR showed it was administered daily at 5:00 p.m. in December 2024 and January 2025. The pharmacy recommendation dated 1/2/25 stated that trazodone had a side effect of increased sedation, that giving it at 5:00 p.m. could lead to a fall, and recommended careful monitoring and consideration of changing the time to bedtime unless clinically contraindicated. An ADON wrote a note on the recommendation sheet stating the medication was given specifically at 1700 for agitation and referenced the physician's 12/9/24 note, but the clinical record contained no physician response to the recommendation. The NP assessed the resident on 1/3/25 and 1/15/24 and made no mention of the pharmacy recommendation, and interviews with the ADON, DON, and NP indicated uncertainty about whether the recommendation had been documented as addressed.
Missed Physician-Ordered PT-INR
Penalty
Summary
Failure to provide timely laboratory services occurred when staff did not obtain a physician-ordered PT-INR for Resident #9 on the day it was scheduled. The clinical record showed a physician order dated 8/25/25 for the PT-INR, and the resident’s care plan directed staff to obtain labs as ordered. During interview, the DON stated the lab scheduled for 8/25/25 was not obtained that day and there were no results available at that time. The DON also stated the responsible person and physician were notified, and the lab was obtained later. Facility documentation reviewed included the policy for lab and diagnostic test results, which states staff are responsible for processing test requisitions and arranging for tests, and that staff must document when, how, and to whom information was provided in the resident’s record.
Therapeutic Diet Not Followed for Resident Meal
Penalty
Summary
Therapeutic diet orders were not followed for one resident, who was ordered a mechanical soft diet with meats served with gravy or sauce and drinks served in coffee mugs. During breakfast observation, the resident’s sausage was served without gravy or sauce and appeared dry, despite the meal ticket indicating regular, mechanical soft, ground meats, and ground meat with gravy. The resident was interviewed and repeatedly pointed at the sausage, saying no, no. The resident’s responsible person stated that the main concern with the facility was the food and reported that the resident does not eat well, the meals need to be more resident-centered, and the meats are dry. A CNA was unsure about the gravy but acknowledged that if it is listed on the ticket, it should be provided. The Dietary Manager stated that when the ticket specifies meat with gravy, the meat should be moistened, and that the ticket should be followed because it is based on physician orders. The clinical record and care plan both reflected the mechanical soft therapeutic diet with gravy or sauce on meats.
Failure to Provide Ordered Meal Assistance and Adaptive Drinking Equipment
Penalty
Summary
The facility failed to provide special eating equipment and utensils for a resident who needed them and did not provide meals as ordered. Resident #36 was observed during breakfast without his fluids served in coffee mugs, even though his meal ticket directed that all drinks be put in coffee mugs and that ground meat be served with gravy. During the observation, the resident had difficulty picking up the glass of milk and stated that he needed handles. He was also observed repeatedly pointing at the sausage and saying no, no, while his responsible person stated that the resident did not eat well, the meals needed to be more resident-centered, and the meats were dry. Interviews confirmed that meal tickets were to be followed when they indicated drinks in coffee mugs, and the Dietary Manager stated that such directions were based on physician orders. The resident’s clinical record showed physician orders for a mechanical soft diet with meats served with gravy or sauce and all drinks served in coffee mugs with meals. Review of the comprehensive care plan did not reflect that all drinks were to be served in coffee mugs with the resident’s meals.
Hand Hygiene Not Followed During Medication Pass
Penalty
Summary
The facility failed to follow infection control practices for hand hygiene on one of four units, Sunset Drive. During a medication pass observation on 8/27/25 at 8:00 a.m., an LPN administered medications to Resident #42 and then washed her hands at the room sink. After washing, the LPN directly touched the faucet handle to turn off the water before drying her hands with a paper towel, and then prepared and administered medications to Resident #2. When interviewed shortly afterward, the LPN stated, "I was probably nervous." At 8:34 a.m., the DON and infection preventionist stated that after washing hands for approximately 20 seconds, hands should be rinsed, dried, and the water turned off with a dry paper towel, and that nurses were not supposed to directly contact faucet handles after washing hands. The facility policy titled Handwashing/Hand Hygiene, revised August 2019, stated that hand hygiene is the primary means to prevent the spread of infections and directed staff to rub hands together vigorously for at least 20 seconds, rinse and dry thoroughly with a disposable towel, and use the towel to turn off the faucet.
Incomplete Documentation of Resident Care
Penalty
Summary
The facility staff failed to maintain a complete and accurate clinical record for one of the residents in the survey sample. Specifically, the resident's activities of daily living (ADL) support logs and food intake logs were not documented multiple times during April 2023. The resident, who had diagnoses including post-surgical hip replacement, urinary tract infection, and venous thrombosis, was assessed as cognitively intact. However, the documentation for eating performance, personal hygiene support, and toilet use was incomplete, with significant gaps in the records. For instance, out of 56 opportunities to document eating support, 37 were not documented, and similar deficiencies were noted in personal hygiene and toilet use documentation. Additionally, the meal percentage intake log showed 59 out of 84 opportunities were not documented. The administrator acknowledged the issue and indicated a need for training, although they were not employed at the time of the concern.
Delayed Toileting Assistance for Resident
Penalty
Summary
The facility staff failed to provide timely toileting assistance to a resident, identified as Resident #3, who was admitted with multiple diagnoses including a femur fracture and urinary tract infection. The resident was assessed as cognitively intact and occasionally incontinent of bowel and bladder. On the evening of April 22, 2023, the resident activated the call light for assistance to the bathroom, which reportedly went unanswered for over an hour, resulting in the resident soiling herself. The nursing note documented that the nurse responded to the call light at approximately 9:10 p.m. and informed the resident that a CNA would assist her, but there was no documentation of toileting or hygiene assistance provided during that shift. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), confirmed the lack of documentation and the delay in response to the resident's call light. The ADON, who worked as a floor nurse during the resident's stay, verified that the evening shift CNA was on duty but did not document any assistance provided. The DON, who was not employed at the facility during the incident, stated that the expected response time for call lights was within 3 to 5 minutes, with a maximum of 10 minutes. The delayed response was deemed unacceptable, and there was no documented follow-up or actions taken in response to the incident. The facility's policy on activities of daily living emphasized the importance of timely assistance, which was not adhered to in this case.
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Illustrative
What surveyors actually found near you
We read the 5 citations issued within 25 miles in the last 12 months — 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near East Lexington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kendal At Lexington | 1 mi | ★★★★★ | 0 | 0 |
| Shenandoah Valley Health And Rehab | 5.3 mi | ★★★★★ | 0 | 0 |
| Alleghany Health And Rehab | 20.1 mi | ★★★★★ | 5 | 0 |
| The Woodlands Health And Rehab Center | 20.5 mi | ★★★★★ | 0 | 0 |
| Brian Center Of Alleghany | 24.2 mi | ★★★★★ | 0 | 0 |
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