Lexington House

Inspectors wroteBased on observation and interview, the facility failed to ensure menus were followed in order to meet the nutritional needs of residents who required a puree diet. The facility failed to follow the established recipes to ensure the nutritional adequacy of the meal for all 18 residents who received a puree diet.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and failed to store food in accordance with professional standards for food service safety. The facility census was 110.

Inspectors wroteBased on record review and interviews the facility failed to ensure grievances/complaints had been documented and investigated. The facility failed to open a grievance/complaint investigation for 1 (#9) of 37 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure that residents who required urostomy services received care consistent with professional standards of practice, as evidenced by the facility failing to ensure the physician's order for nephrostomy tube irrigation was followed for 1 (Resident #35) of 1 residents reviewed for catheter care. Total sample size:

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident's therapeutic diet was followed according to the physician's orders by failing to ensure a resident received double portion on her lunch tray for 1 resident (#14) in a total sample of 37 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all mechanical, electrical, and patient care equipment were maintained in a safe operating condition for 1 (Resident #113) of 6 residents reviewed for physical environment. The total sample size was 37 residents. Review of facility policy with a last review date of 07/2025, titled Housekeeping Safety, revealed in part . Check for and report all defective equipment. Review of Resident #113's medical record revealed Resident #113 was admitted to the facility on [DATE] with diagnoses that included, in part., Parkinson's disease without Dyskinesia with Fluctuations, Neurocognitive Disorder with Lewy Bodies, and Essential Tremor. Review of Resident #113's Significant Change MDS with ARD 04/16/2026 revealed the resident had a BIMS score of 12, indicating moderate cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure reasonable accommodation of needs by failing to ensure the call light was accessible by a resident for 3 (Resident #2, Resident #3, and Resident R4) of 4 sampled residents. Review of the facility's policy titled Call Light/Bell revised 01/2024 revealed, in part.place the call light within the resident's reach before leaving the room. Resident #2Review of Resident #2's EMR revealed an admission date of 03/31/2022 with diagnoses including Hemiplegia and Hemiparesis, Generalized Muscle Weakness, Repeated Falls, and Personal History of Healed Traumatic Fracture. Review of Resident #2's Quarterly MDS with ARD of 10/07/2025 revealed a BIMS score of 13, indicating intact cognition. Resident #2 was dependent for toileting, hygiene, bathing, dressing, rolling, and transfers. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation of an injury of unknown origin for 1 (Resident #1) of 4 sampled residents. Review of the facility's Critical Incident Report dated 12/08/2025 revealed Resident #1 complained of pain to her right lower extremity and x-rays revealed fractures of the tibial shaft and the proximal fibula. Statements were obtained from nursing staff who rendered care during the 48 hours prior to discovery of the injury. The facility substantiated an Injury of Unknown Origin. Review of the facility's policy titled Incident Investigation and Reporting revised 05/2024 revealed, in part. [...]

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure that each Resident was treated with respect and dignity and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #2) out of 3 (Resident #1, Resident #2, and Resident #3) sampled Residents, by failing to ensure staff displayed respect when speaking to Resident #2.

Inspectors wroteBased on observations and interviews, the facility failed to ensure recipes for pureed diets were followed during meal preparation. This failed practice had the potential to affect 12 residents (#6, #11, # 36, #37, #46, #53, #58, #69, #71, #76, #85, and #101) who received pureed diets.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean and sanitary kitchen to prevent the likelihood of foodborne illnesses and failed to store, prepare, and serve food in accordance with professional standards for food service safety. The deficient practice had the potential to effect all of the residents who received meals from the kitchen. There were 115 residents who resided in the facility. The facility failed to ensure: 1. Food items in the pantry were labeled with an open date; 2. Staff were wearing hair restraints including beard restraints to prevent hair from contacting food; 3. Maintenance of a clean and sanitary kitchen at all times; and 4. Dishes were sanitized appropriately.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received reasonable accommodation of needs by failing to ensure the call light was accessible by a resident for 1 (Resident #7) of 41 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure the SNF ABN Form CMS-10055 (Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage Form CMS-10055) was provided to the resident and/or the resident's responsible party prior to the discontinuation of Medicare Part A services for 2 (#34 and #61) of 2 residents reviewed for Beneficiary Notification who required the notification.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure the person-centered care plans were developed and implemented for 2 (#25 and #90) of 41 sampled residents. The facility failed to: 1. Ensure Resident #25 did not have a cigarette and lighter in his/her possession, as care planned; and 2. Ensure a care plan was developed timely for Resident #90 to address her known history of eating non-food items.

Inspectors wroteResident #11 Review of Resident #11's medical record revealed an admit date of 02/28/2012 and a readmission date of 01/16/2023 with diagnoses that included in part .Chronic Respiratory Failure with Hypoxia, Dysphagia, Cognitive Communication Deficit, Stage 3 Chronic Kidney Disease and Pressure Ulcer of Sacral Region, Stage 3. Review of Resident #11's Significant Change MDS with an ARD of 05/01/2025 revealed a BIMS was not conducted because the resident was rarely or never understood. Further review revealed Resident #11 was dependent on staff with eating, toileting hygiene, rolling left and right, sitting to lying, and chair/bed to chair transferring. Review of Resident #11's current physician's orders revealed the following: 05/03/2025: Clean Stage 3 to sacrum with wound cleanser, pat dry, apply Santyl ointment to wound, and cover with a dermadress dressing every day until healed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services that assured accurate acquiring, receiving, dispensing and/or administration of medications to meet the needs of each resident. The facility had a total census of 115 residents. The facility failed to: 1. Ensure an accurate account for controlled medications was completed at the time of administering narcotics on 1 (Cart 4) of 4 (Cart 1, Cart 2, Cart 3, and Cart 4) medication carts for Resident #28; and 2. Ensure proper nursing procedures and documentation were completed at the time of wasting/destroying narcotics on 1 (Cart 1) of 4 (Cart 1, Cart 2, Cart 3, and Cart 4) medication carts for Resident #1

Inspectors wroteBased on record review, observation, and interview the facility failed to provide fluids sufficient to maintain adequate hydration. The facility failed to provide a water pitcher or any fluid for hydration at the bedside to 1 (Resident #37) of 41 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure services were provided to meet professional standards of quality by failing to ensure a resident with a UTI received timely and appropriate treatment for 1 (#1) of 3 (#1, #2, & #3) sampled residents reviewed for UTIs.

Inspectors wroteBased on observation and interview, the facility failed to maintain an effective pest control program by failing to ensure the facility was free from insects. The deficient practice had the potential to affect 113 residents who resided in the facility.

Inspectors wroteBased on observation and interview the facility failed to ensure a cognitively impaired resident was treated with respect and dignity and cared for in a manner that promotes enhancement of his or her own quality of life. The facility failed to ensure that thickened water placed in front of the resident was offered as a drink for 1 (Resident #11) resident reviewed for dignity in a total sample of 28.

Inspectors wroteBased on observations and interview, the facility failed to maintain a clean, comfortable, and homelike environment, by failing to ensure blinds were functioning properly in Room A. Total sample size 28.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who were unable to carry out ADL's (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide nail care for 1 (Resident #13) of 28 residents sampled for ADL's.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure that a Resident received treatment and care in accordance with professional standards of practice for 1 (Resident #20) of 28 Sampled Residents. The facility failed to ensure physician orders to treat a newly identified wound were transcribed into the resident's medical record, and failed to perform and document a wound assessment of the newly identified wound.

Inspectors wroteBased on observation and interview the facility failed to store and serve food in accordance with professional standards for food service safety for all 110 oral intake residents in the facility.

Inspectors wroteBased on observation and interview the facility failed to treat residents with respect and dignity for 1 (Resident #4) of 4 (Resident #1, Resident #2, Resident #3, and Resident #4) residents reviewed for resident rights.