Lexington Health Care Center

Inspectors wroteBased on record review and interviews with resident, family, Medical Director, and staff, the facility failed to treat a resident in a dignified manner when staff filed legal guardianship of the resident without communicating with the resident or the resident's family and without having the resident evaluated or assessed to be deemed incompetent. Resident #1, with visible tears in her eyes, stated she felt the facility was trying to control her and take her rights away. This affected 1 of 1 resident reviewed for dignity and respect (Resident #1).

Inspectors wroteBased on record review, staff, resident and law enforcement interviews, the facility failed to honor a resident's right to refuse treatment when the resident declined five hemodialysis (a life-sustaining procedure for kidney failure that uses a machine to filter waste, toxins, and excess fluids from the blood) treatments and the facility proceeded to file an involuntary commitment which deemed the resident a danger to herself. The resident reported once the local law enforcement officer had walked her out to the front entrance of the facility, the resident was asked to put her hands out and the officer placed handcuffs on both wrists in the front of her body and had her sit in the backseat of the police car. The resident stated she did not know what was happening as she had no previous experience with law enforcement. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to label and date food items stored for use, reseal dry goods that were left open to air, keep a gas range and oven clean of grime (ingrained dirt or filth accumulated on a surface) and grease build-up, and maintain a clean food preparation area. These practices occurred in 1 of 3 reach-in coolers (cooler #2), 1 of 1 dry goods storage room and had the potential to affect food served to residents.

Inspectors wroteBased on observations, record review, and Responsible Party (RP), continuous radar-monitoring system representatives, and staff interviews, the facility failed to obtain written consent and educate the resident or Responsible Party for the use of a continuous radar-monitoring system mounted on the wall above the resident's bed for 1 of 2 sampled residents with a monitoring system (Resident #35).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure a Preadmission Screening Resident Review (PASRR) was completed prior to admission to the facility for a resident with a diagnosis of a serious mental illness for 1 of 1 resident reviewed for PASRR (Resident #45).

Inspectors wroteBased on observations, record review and Medical Director, Nurse Practitioner, staff and resident interviews the facility failed to provide the necessary assistance to obtain dental services for 1 of 2 residents reviewed for dental services (Resident #57).

Inspectors wroteBased on record review, and resident and staff interviews, the facility failed to report reasonable suspicion of a crime to law enforcement when Resident #1 was identified with an odor of marijuana after he returned inside the facility from the smoking area. A subsequent drug screen was completed and the resident tested positive for Tetrahydrocannabinol (THC [the main psychoactive ingredient in marijuana] ). This deficient practice affected 1 of 3 residents reviewed for accidents (Resident #1).

Inspectors wroteBased on record review, and resident and staff interviews, the facility failed to complete smoking assessments when a resident was identified as a smoker and to provide supervision and retain smoking materials in accordance with the smoking policy for a resident assessed as a supervised smoker for 1 of 3 residents reviewed for accidents (Resident #1).

Inspectors wroteBased on observation, record review, and interviews with staff, Nurse Practitioner, Pharmacist, and Physician the facility failed to ensure a nurse accurately measured a liquid narcotic medication per professional standards of practice resulting in a wrong administration dose. This was for 1 of 3 residents whose medications were reviewed (Resident #1).

Inspectors wroteBased on record review, and staff interview the facility failed to ensure a resident's medical record was complete regarding medication orders given by a Nurse Practitioner and documentation of the administration of medications. This was for 1 of 3 of three sampled residents whose medications were reviewed (Resident # 1).

Inspectors wroteBased on record review, and resident, family member, neighbor and staff interviews, the facility failed to protect a resident's right to be free from exploitation. In [DATE], Nurse Aide (NA) #1 told Resident #1 that her landlord raised the rent at her apartment and she was going to be evicted. Resident #1 reported that NA #1 asked to live in his personal home and being a goodhearted trusting person, he was considering letting NA #1 and her friend house-sit his personal home while he was at the facility. NA #1 asked the resident if she could look at his house and he informed her where the keys were located. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to report an allegation misappropriation of property/exploitation to Adult Protective Services (APS) for 1 of 3 residents reviewed for abuse, misappropriation of property and/or exploitation (Resident #1).

Inspectors wroteBased on record review, observations, and interviews with staff, resident and Nurse Practitioner, the facility failed to: 1) provide oxygen at the rate ordered by the physician: provide clean air intake filters on oxygen concentrators for 1 of 5 residents (Resident #79); 2) post oxygen signs for 3 of 5 residents (Resident #10, Resident #13, and Resident #33); 3) change oxygen tubing for 2 of 5 residents (Resident #10 and Resident #33); and 4) obtain physician's order for oxygen delivery for 1 of 5 residents (Resident #250) reviewed for respiratory care.

Inspectors wroteBased on observations, record review, and resident and staff interviews, the facility failed to allow residents who were assessed to be safe smokers to smoke independently per their individual preference for 2 of 3 residents (Resident #8 and #249) reviewed for smoking.

Inspectors wroteBased on record review and staff and resident interviews, the facility failed to resolve grievances that were reported in the Resident Council meetings for 4 of 6 months (11/19/2024, 12/18/2024, 1/29/2025 and 2/26/2025).

Inspectors wroteBased on record review and staff interviews, the facility failed to completely fill out the Do Not Resuscitate (DNR) form for 1 of 2 residents reviewed and Advanced Directives (Resident # 30).

Inspectors wroteBased on record review and Nurse Practitioner and staff interviews, the facility failed to notify the Nurse Practitioner (NP) after an International Normalized Ratio (INR) test (monitors the effectiveness of blood-thinning medications) was not completed as ordered for 1 of 1 resident (Resident # 255) reviewed for monitoring anticoagulant medicine.

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to ensure a resident swallowed medications during medication administration when Nurse #5 left medications at the bedside for 1 of 5 residents observed for medication administration (Resident #2).

Inspectors wroteBased on observations, record reviews and staff and Psychiatric Nurse Practitioner interviews, the facility failed to provide the necessary supervision to prevent a resident with known wandering behaviors from entering the room of another resident and attempting to take the other resident's (Resident #94's) belongings during the night for 1 of 3 residents reviewed for accidents (Resident #91).

Inspectors wroteBased on record review, observations, and staff interviews, the facility failed to store a plastic enteral feeding syringe with the plunger separated from the barrel of the syringe for 1 of 3 residents (Resident #79) reviewed for enteral feeding management. This practice had the potential for bacterial growth and contamination.

Inspectors wroteBased on record review and staff and Nurse Practitioner interviews, the facility failed to complete an International Normalized Ratio (INR) test as ordered by the physician for 1 of 1 resident (Resident # 255) reviewed for monitoring anticoagulant medicine.

Inspectors wroteBased on record review and staff interviews, the facility failed to revise a care plan for an indwelling urinary catheter for 1 of 3 residents whose care plans were reviewed (Resident #1).

Inspectors wroteBased on record review and staff interviews, the facility failed to maintain accurate medical records in the area of medication management for 1 of 3 residents reviewed for accurate medical records (Resident #1).

Inspectors wroteBased on record review, observation, and interviews with staff, the facility failed to protect the resident's right to be free from misappropriation of controlled medications for 1 of 3 residents reviewed for misappropriation of a resident's property (Resident #3). The resident received her pain medication as scheduled.

Inspectors wroteBased on observation, record review, staff interviews, the facility failed to care for a resident in a safely manner for 1 of 3 residents were reviewed for accidents (Resident #5). Resident #1 was assisted by Hospice Aide #1 during a bed bath and the resident fell to the floor.

Inspectors wroteBased on observations and interviews with the staff and Regional Director of Culinary Operations, the facility failed to seal, label/date, and discard expired food items stored in the Dietary Department's walk-in freezer, reach-in refrigerators, and 1 of 2 Nourishment Rooms observed (100 Hall Nourishment Room).

Inspectors wroteBased on staff interviews and record review, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions put into place by the Committee after each of the following surveys with citations that were recited on the current recertification / complaint survey of 2/21/24: 1) The annual recertification / complaint investigation survey of 1/10/22. This was evident for three recited deficiencies in the areas of Accuracy of Assessments (F641); Development and Implementation of Comprehensive Care Plans (F656); and Posted Nurse Staffing Information (F732). 2) The annual recertification / complaint investigation survey of 10/14/22. This was also evident for four recited deficiencies in the areas of Notification of Changes (F580); Development and Implementation of Comprehensive Care Plans (F656); [...]

Inspectors wroteBased on record reviews, Nurse Practitioner (NP), resident and staff interviews the facility failed to notify the NP when a resident experienced pain and the acetaminophen order expired for 1 of 2 (Residents #43) residents sampled for change in condition.

Inspectors wroteBased on staff interviews and record review, the facility failed to submit an initial report of an abuse allegation to the State Agency within the required 2- hour time frame for 1 of 3 residents (Resident #32) reviewed for abuse.

Inspectors wrote2. Resident #80 was admitted to the facility on [DATE]. The discharge Minimum Data Set (MDS) assessment dated [DATE] documented Resident #80 was discharged to a short-term general hospital on [DATE]. A physician order dated 11/26/2023 ordered Resident #80 to be discharged home with home health services. A nursing note dated 11/26/2023 documented Resident #80 discharged home on [DATE]. A nurse practitioner (NP) note dated 11/27/2023 documented that Resident #80 was discharged to home on [DATE]. An interview was conducted with MDS Nurse #1 and MDS Nurse #2 on 2/21/2023 at 12:12 PM. MDS Nurse #1 reported the discharge MDS assessment for Resident #80 should have been coded for discharge home. MDS Nurse #2 explained she made an error when documenting on the discharge MDS for Resident #80. The Administrator was interviewed on 2/21/2023 at 2:36 PM. [...]

Inspectors wroteBased on record reviews and staff interviews, the facility failed to complete an annual comprehensive Minimum Data Set (MDS) assessment for 1 of 28 residents reviewed for MDS assessments (Resident #54).

Inspectors wroteBased on record reviews, observations, and staff interviews, the facility failed to update care plan interventions related to fall prevention (Resident #44) and behavioral interventions (Resident #54) for 2 of 28 residents reviewed for care plan accuracy.

Inspectors wroteBased on staff interviews and facility and hospital record reviews, the facility failed to review and revise the comprehensive care plan related to a medication that was discontinued after the resident underwent bilateral above knee amputations (AKA). This occurred for 1 of 28 residents (Resident #79) whose care plans were reviewed.

Inspectors wroteBased on record review and Family Member, staff, and Nurse Practitioner interviews the facility failed to provide a safe discharge for 1 of 3 residents (Resident #1) reviewed for discharge from the facility. Resident #1 was discharged home on [DATE] to an independent living apartment with Family Member #1 who was not capable of providing care and the facility did not notify Adult Protective Services the resident discharged without a care giver that could provide toileting and bathing. Resident #1 fell and was transported to the hospital shortly after arriving home from the facility.