Lexington Healthcare and Rehabilitation Center

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement interventions and provide supervision to prevent accidents/injuries to residents related to: 1) failure to prevent a fall with injuries for one resident (#56) out of four residents reviewed for falls; and 2) failure to ensure a safe environment for residents to smoke for two residents (#21, #41) out of two residents who required the use of a wheelchair. Residents were expected to sign a leave of absence (LOA) form and then navigate off facility grounds, unassisted, through the parking lot approximately 350 feet, over a large speed bump, and across large potholes, despite being assessed to require supervision during ambulation or requiring the use of a wheelchair.

Inspectors wroteBased on observation and interviews, the facility failed to ensure the kitchen was maintained in a clean, sanitary manner in one kitchen (Main) of one kitchens observed during survey.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure dependent residents received assistance with activities of daily living (ADLs) for five residents (#107, #86, #18, #43 and #102) of seven residents sampled.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide incontinence care and prevent a Urinary Tract Infection (UTI) for one resident (#150) out of three residents sampled. Findings Included: During a phone interview on 07/15/2025 at 5:15 p.m., Resident #150 Family Member (FM) stated Resident #150 has been in and out of the hospital related to UTI's, multiple times. When she picks up Resident #150's laundry it is soaking wet. Maybe if they changed her more often, she would not have so many UTI's. When she goes to the hospital and they do lab work it shows E. coli [Escherichia coli] in her urine. Review of Resident #150's admission record revealed an admission date of 06/01/2022. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the transmission of communicable diseases and infections as evidenced by 1) failure of staff to provide appropriate incontinence care by two staff members (Staff A, Staff B); 2) failure to implement policies related to staff use of artificial fingernails and containment of long hair for two staff members (Staff K, Staff S); and 3) failure to ensure staff donned Personal Protective Equipment (PPE) in a contact isolation room for two staff members (Staff AA, Staff AB) out of six staff members observed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an assessment for self-administration of enteral nutrition was completed for one resident (#125) out of one resident reviewed.

Inspectors wroteBased on interviews and record review, the facility failed to report allegations of serious injury of unknown source and neglect for one resident (#56) of two residents sampled.

Inspectors wroteBased on record review and interviews, the facility failed to notify a resident and the resident's representative of a hospital transfer in writing prior to the transfer for one resident (#149) out of four residents reviewed.

Inspectors wroteBased on interviews and record reviews, the facility failed to notify the state mental health authority/state intellectual disability authority after a significant change in the mental or physical condition of a resident who has mental illness for one resident (#3) of nine residents reviewed.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to implement patient-centered interventions related to adaptive dining equipment to promote independence while eating per occupational therapy and physician order for one resident (#13) out of one resident reviewed.

Inspectors wroteBased on observations, record reviews, and interviews the medical physician failed to provide the facility with written, signed and dated progress notes following each visit for one (#13) of 34 sampled residents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure medications were administered per physician orders and failed to document physician notification for missed medications for one resident (#110) of one dialysis residents reviewed.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-six medication administration opportunities were observed and two errors were identified for one (#23) of eight residents observed. These errors constituted a 7.69% medication error rate.

Inspectors wroteBased on observation, record review, and interviews the facility failed to ensure food allergies were accommodated for one resident (#23) of one resident sampled for food allergies.

Inspectors wroteBased on observations, interviews, and record reviews, the facility did not ensure an effective infection prevention program was implemented for four out of four residents reviewed for on-going skin rashes.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to facilitate timely care plan meeting notifications to allow the representative or resident to participate in the care plan meetings, and failed to provide care plan summaries of the meetings to the representatives and/or three residents (#6, #17, and #23) of three sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to include the resident representative in all aspects of the person-centered care planning and the right to participate in the care and treatment planning and process for one (Resident #72) out of fifty-one sampled residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide one (Resident #134) of 51 residents with a written notification for a room change.

Inspectors wroteBased on record review and interview, the facility failed to ensure one (Resident #19) of fifty-one sampled residents was assessed upon admission related to activities.

Inspectors wroteBased on record review and interview, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for three (Residents #90, #47 and #38) of four residents sampled for PASARR Level II

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure care plan interventions were implemented for three (Residents #19, #98, and #114) of fifty-one sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (Resident #19) of fifty-one sampled residents, was offered and provided assistance to activities of her choice during two of four days observed (3/19/2023, and 3/20/2023).

Inspectors wroteBased on interview and record review, the facility failed to monitor for behaviors and side effects for psychotropic medications for one (Resident #9) of five residents reviewed for unnecessary medications. The facility also failed to limit as needed antianxiety medication for one (Resident #9) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (Residents #98 and #114) of fifty-one sampled residents were provide with food items of choice and preference; and failed to ensure Resident #114 received a meal tray which did not include items she was allergic to, during two of four days observed on 3/19/2023, and 3/21/2023. Findings Included: On 3/19/2023 at 12:10 p.m. Resident #98 was observed seated in the main dining room and eating her meal. She waved over this writer as she wanted to talk about what she was served. Her meal tray/plate was observed with what appeared to be two slices of thick turkey, brown gravy on the turkey, mashed potatoes with what appeared to be brown gravy on it, and bread stuffing with what appeared to be a brown gravy all over it. The brown gravy was on all three main food items. Photographic evidence was taken. [...]

Inspectors wroteBased on interview, record review, and interview, the facility failed to maintain an ongoing infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one month (March) of three months reviewed. The facility also failed to maintain an ongoing surveillance program to prevent reoccurring urinary tract infections for one (Resident #80) of 51 sampled residents.

Inspectors wroteBased on observations, interviews, record review and review of the Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to implement an infection control and prevention program to prevent possible transmission of Coronavirus Disease 2019 (COVID-19) as evidenced by their failure to ensure that facility staff members, seven of which were observed, were screened for signs and symptoms each day before working and failed to supervise the screening of three visitors prior to entry to the facility with the potential to expose a total of 146 residents for two of two days observed.

Inspectors wroteBased on observations, staff and resident interviews and medical record review, the facility failed to develop care plan problem areas with goals and interventions for one resident (#192), related to use of antibiotics for infections and failed to implement care plan interventions for one resident (#94), related to not using fall floor mats when the resident was in bed of 51 sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify, examine, and assess a change of condition in accordance with the professional standards of practice for one resident (#84) related to discolorations and bruises on the resident's left upper arm out of 51 sampled residents.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain drugs and biologicals used in the facility in a safe, secure, and orderly manner in one medication room (200 Wing) of four medication rooms, and failed to properly dispose of a medication patch for one resident (#50) of 35 residents on a pain management program.